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Hoyer-Kuhn H, Eckert AJ, Binder G, Bonfig W, Dübbers A, Riedl S, Woelfle J, Dörr HG, Holl RW. Impact of Newborn Screening on Adult Height in Patients With Congenital Adrenal Hyperplasia (CAH). J Clin Endocrinol Metab 2023; 108:e1199-e1204. [PMID: 37256841 DOI: 10.1210/clinem/dgad307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
CONTEXT Treatment of children with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is challenging. Linear growth and adult height are compromised according to recent publications. However, most of these data were obtained in the era before CAH newborn screening. DESIGN Body height of patients with classical CAH diagnosed before and after the establishment of newborn screening were analyzed retrospectively. PATIENTS AND METHODS We identified 600 patients with classical CAH (227 male) with data on near-adult height (NAH), target height (TH), and information on newborn screening from the electronic German CAH registry (German Society for Paediatric Endocrinology and Diabetology). Newborn screening was performed in 101 (16.8%) patients. All patients received hydrocortisone with or without fludrocortisone.To assess the effects of newborn screening, a linear regression model adjusted/stratified for sex and phenotype was used (SAS 9.4). RESULTS TH corrected NAH (mean; 95% confidence interval) was closer to 0 in patients with CAH and newborn screening [-0.25 standard deviation score (SDS); -0.44 to -0.06] than in patients without newborn screening (-0.44 SDS; -0.52 to -0.36) (P = .069). Screening had no effect on NAH in female patients. In male patients, NAH was significantly better (P = .033) with screening than without screening. After stratifying for CAH phenotype, screening did not affect the NAH of patients with salt-wasting CAH. Patients with simple-virilizing CAH had a significantly better cNAH (P = .034) with screening (0.15 SDS; -0.28-0.59) than without screening (-0.35 SDS; -0.52 to -0.18). CONCLUSIONS Our data suggest that newborn screening might be associated with improved NAH in male CAH patients and in patients with simple-virilizing CAH.
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Affiliation(s)
- Heike Hoyer-Kuhn
- Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Alexander J Eckert
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, 89081 Ulm, Germany
| | - Gerhard Binder
- Pediatric Endocrinology, University-Children's Hospital Tübingen, 72076 Tübingen, Germany
| | - Walter Bonfig
- Department of Pediatrics, Klinikum Wels-Grieskirchen, 4600 Wels, Austria
- Department of Pediatrics, Technical University of Munich, TUM School of Medicine, 80804 Munich, Germany
| | - Angelika Dübbers
- Department of Pediatrics, University Hospital Münster, 48149 Münster, Germany
| | - Stefan Riedl
- Division of Pediatric Pulmology, Allergology and Endocrinology, Department of Pediatrics, Medical University of Vienna, 1090 Wien, Austria
- Department of Pediatrics, St. Anna Kinderspital, Medical University of Vienna, 1090 Wien, Austria
| | - Joachim Woelfle
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Helmuth G Dörr
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, 89081 Ulm, Germany
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Reyes AP, León NY, Frost ER, Harley VR. Genetic control of typical and atypical sex development. Nat Rev Urol 2023:10.1038/s41585-023-00754-x. [PMID: 37020056 DOI: 10.1038/s41585-023-00754-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 04/07/2023]
Abstract
Sex development relies on the sex-specific action of gene networks to differentiate the bipotential gonads of the growing fetus into testis or ovaries, followed by the differentiation of internal and external genitalia depending on the presence or absence of hormones. Differences in sex development (DSD) arise from congenital alterations during any of these processes, and are classified depending on sex chromosomal constitution as sex chromosome DSD, 46,XY DSD or 46,XX DSD. Understanding the genetics and embryology of typical and atypical sex development is essential for diagnosing, treating and managing DSD. Advances have been made in understanding the genetic causes of DSD over the past 10 years, especially for 46,XY DSD. Additional information is required to better understand ovarian and female development and to identify further genetic causes of 46,XX DSD, besides congenital adrenal hyperplasia. Ongoing research is focused on the discovery of further genes related to typical and atypical sex development and, therefore, on improving diagnosis of DSD.
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Affiliation(s)
- Alejandra P Reyes
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Genetics Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Nayla Y León
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Emily R Frost
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Vincent R Harley
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.
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Wada T, Nishigaki S, Hata A, Maeyama T, Ida S, Etani Y, Kawai M. Dosage of hydrocortisone during late infancy is positively associated with changes in body mass index during early childhood in patients with 21-hydroxylase deficiency. Endocr J 2023; 70:333-340. [PMID: 36504089 DOI: 10.1507/endocrj.ej22-0466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Obesity is a major complication in children with 21-hydroxylase deficiency (21-OHD). There is evidence to show that higher body mass index (BMI) during infancy and early childhood is associated with an increased risk for the subsequent development of obesity in the general population; however, limited information is currently available on this issue in 21-OHD patients. Additionally, despite the frequent use of supraphysiological dosages of hydrocortisone in 21-OHD, the association between BMI and hydrocortisone dosage during these periods remains largely unclear; therefore, we retrospectively investigated BMI at approximately 1 and 3 years old and its association with hydrocortisone dosage in 56 children with 21-OHD. The median BMI-standard deviation score (SDS) was 0.28 (Interquartile range [IQR]: -0.53 to 1.09) and 0.39 (IQR: -0.44 to 1.14) at approximately 1 and 3 years old, respectively, and no association was observed between hydrocortisone dosage and BMI-SDS at either time-point; however, multivariate analysis revealed that hydrocortisone dosage at approximately 1 year old was positively associated with changes in BMI (β = 0.57, p = 0.013) and BMI-SDS (β = 0.59, p = 0.011) between approximately 1 and 3 years old after adjustment for age, sex, and changes in hydrocortisone dosage during the same period. The average dosage of hydrocortisone between approximately 6 months and 1 year old also showed similar results. These results indicate that a higher dosage of hydrocortisone during late infancy is associated with a higher BMI at approximately 3 years old, which may lead to the development of obesity later in life in children with 21-OHD.
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Affiliation(s)
- Tamaki Wada
- Department of Gastroenterology, Nutrition, and Endocrinology, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
| | - Satsuki Nishigaki
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
| | - Ayaha Hata
- Department of Gastroenterology, Nutrition, and Endocrinology, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
| | - Takatoshi Maeyama
- Department of Gastroenterology, Nutrition, and Endocrinology, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
| | - Shinobu Ida
- Department of Clinical Laboratory, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
| | - Yuri Etani
- Department of Gastroenterology, Nutrition, and Endocrinology, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
| | - Masanobu Kawai
- Department of Gastroenterology, Nutrition, and Endocrinology, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
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Itonaga T, Hasegawa Y. Monitoring treatment in pediatric patients with 21-hydroxylase deficiency. Front Endocrinol (Lausanne) 2023; 14:1102741. [PMID: 36843618 PMCID: PMC9945343 DOI: 10.3389/fendo.2023.1102741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
21-hydroxylase deficiency (21-OHD) is the most common form of congenital adrenal hyperplasia. In most developed countries, newborn screening enables diagnosis of 21-OHD in asymptomatic patients during the neonatal period. In addition, recent advances in genetic testing have facilitated diagnosing 21-OHD, particularly in patients with equivocal clinical information. On the other hand, many challenges related to treatment remain. The goals of glucocorticoid therapy for childhood 21-OHD are to maintain growth and maturation as in healthy children by compensating for cortisol deficiency and suppressing excess adrenal androgen production. It is not easy to calibrate the glucocorticoid dosage accurately for patients with 21-OHD. Auxological data, such as height, body weight, and bone age, are considered the gold standard for monitoring of 21-OHD, particularly in prepuberty. However, these data require months to a year to evaluate. Theoretically, biochemical monitoring using steroid metabolites allows a much shorter monitoring period (hours to days). However, there are many unsolved problems in the clinical setting. For example, many steroid metabolites are affected by the circadian rhythm and timing of medication. There is still a paucity of evidence for the utility of biochemical monitoring. In the present review, we have attempted to clarify the knowns and unknowns about treatment parameters in 21-OHD during childhood.
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Affiliation(s)
- Tomoyo Itonaga
- Department of Pediatrics, Oita University Faculty of Medicine, Oita, Japan
- *Correspondence: Tomoyo Itonaga,
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Aureli A, Bocchini S, Mariani M, Crinò A, Cappa M, Fintini D. A rare occurrence of non-classic congenital adrenal hyperplasia and type 1 diabetes mellitus in a girl with Prader-Willi Syndrome: Case report and review of the literature. Front Endocrinol (Lausanne) 2023; 14:1148318. [PMID: 37124733 PMCID: PMC10130376 DOI: 10.3389/fendo.2023.1148318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Prader-Willi syndrome (PWS) is a rare genetic disorder resulting from lack of expression of the paternally derived chromosome 15q11-13, associated with several complications, including pubertal disorders, short stature, hyperphagia, obesity, glucose metabolism abnormalities, scoliosis, obstructive sleep apnea syndrome (OSAS) and behavioral problems. We report the case of a girl affected by PWS who presented at the age of 5.9 with premature pubarche, accelerated linear growth and advanced bone age (BA). She was subsequently diagnosed with non-classic congenital adrenal hyperplasia (CAH) confirmed by genetic analysis. Considering the clinical, biochemical, and genetic findings, hydrocortisone therapy was started to prevent rapid BA acceleration and severe compromission of final height. During infancy, short stature and low levels of insulin-like growth factor-1 (IGF-1) for age and gender led to suspicion of growth hormone deficiency (GHD), confirmed by stimulation testing (arginine and clonidine). rhGH therapy was administered and continued until final height was reached. During endocrinological follow up she developed impaired glucose tolerance with positive markers of β-cell autoimmunity (anti-glutamic acid decarboxylase antibodies, GAD Ab), which evolved over time into type 1 diabetes mellitus and insulin therapy with a basal-bolus scheme and an appropriate diet were needed.
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Affiliation(s)
- Alessia Aureli
- Prader-Willi Reference Center, Endocrinology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Sarah Bocchini
- Prader-Willi Reference Center, Endocrinology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Michela Mariani
- Prader-Willi Reference Center, Endocrinology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Antonino Crinò
- Center for Rare Diseases and Congenital Defects, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Marco Cappa
- Prader-Willi Reference Center, Endocrinology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Danilo Fintini
- Prader-Willi Reference Center, Endocrinology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
- *Correspondence: Danilo Fintini,
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Ozdemir Dilek S, Turan I, Gurbuz F, Celiloglu C, Yuksel B. The utility of annual growth velocity standard deviation scores and measurements of biochemical parameters in long-term treatment monitoring of children with 21-hydroxylase deficiency. Hormones (Athens) 2022; 21:391-397. [PMID: 35243601 DOI: 10.1007/s42000-022-00354-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/02/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to investigate the utility of annual growth velocity (GV) standard deviation scores (SDSs) and compatibility and effectiveness of biochemical parameters in long-term treatment monitoring and management of 21-hydroxylase deficiency (21-OHD) in children. METHODS Fifty children with 21-OHD were included in this study, and the biochemical parameters obtained during 402 visits were retrospectively evaluated. The follow-up period was divided between two GV SDS groups (GV SDS < 2 and GV SDS ≥ 2) and compared with auxological, biochemical, and clinical findings. RESULTS Elevation of 17-hydroxyprogesterone (17-OHP) values was observed at 193/402 visits, and both adrenocorticotropic hormone (ACTH) and total testosterone (tT) were observed at 53 of 193 (27.5%) visits. The calculated cut-off value for 17-OHP was > 4.3 ng/ml, with a sensitivity of 85.48% and specificity of 37.59% in the GV SDS ≥ 2 group. In the GV SDS ≥ 2 group, the corrected final height SDS (cFH SDS) was lower, and the delta height was higher than in the GV SDS < 2 group (p = 0.005 and p = 0.008, respectively). Linear regression analysis of the GV SDSs revealed that 17-OHP values and the hydrocortisone dose (mg/m2) were affected (β = 0.037, p = 0.035, and β = - 0.147, p = 0.001, respectively). CONCLUSIONS Annual GV was critical in the final height (FH) of children with 21-OHD. However, we observed inconsistency between the biochemical parameters in the follow-ups, and there were difficulties in evaluating these markers. Therefore, annual GV SDSs and biochemical findings should be used together in patients with 21-OHD at follow-ups.
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Affiliation(s)
- Semine Ozdemir Dilek
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ihsan Turan
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey.
| | - Fatih Gurbuz
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Can Celiloglu
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Bilgin Yuksel
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey.
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Nordenström A, Lajic S, Falhammar H. Long-Term Outcomes of Congenital Adrenal Hyperplasia. Endocrinol Metab (Seoul) 2022; 37:587-598. [PMID: 35799332 PMCID: PMC9449109 DOI: 10.3803/enm.2022.1528] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/11/2022] Open
Abstract
A plethora of negative long-term outcomes have been associated with congenital adrenal hyperplasia (CAH). The causes are multiple and involve supra-physiological gluco- and mineralocorticoid replacement, excess adrenal androgens both intrauterine and postnatal, elevated steroid precursor and adrenocorticotropic hormone levels, living with a congenital condition as well as the proximity of the cytochrome P450 family 21 subfamily A member 2 (CYP21A2) gene to other genes. This review aims to discuss the different long-term outcomes of CAH.
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Affiliation(s)
- Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Corresponding author: Henrik Falhammar. Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden Tel: +46-851776411, Fax: +46-851773096, E-mail:
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Al-Rayess H, Addo OY, Palzer E, Jaber M, Fleissner K, Hodges J, Brundage R, Miller BS, Sarafoglou K. Bone Age Maturation and Growth Outcomes in Young Children with CAH Treated with Hydrocortisone Suspension. J Endocr Soc 2022; 6:bvab193. [PMID: 35047717 PMCID: PMC8758402 DOI: 10.1210/jendso/bvab193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Indexed: 11/19/2022] Open
Abstract
Background Young children with congenital adrenal hyperplasia (CAH) require small doses (0.1-1.25 mg) of hydrocortisone (HC) to control excess androgen production and avoid the negative effects of overtreatment. The smallest commercially available HC formulation, before the recent US Food and Drug Administration approval of HC granules, was a scored 5-mg tablet. The options to achieve small doses were limited to using a pharmacy-compounded suspension, which the CAH Clinical Practice Guidelines recommended against, or splitting tablets into quarters or eighths, or dissolving tablets into water. Methods Cross-sectional chart review of 130 children with classic CAH treated with tablets vs a pharmacy-compounded alcohol-free hydrocortisone suspension to compare growth, weight, skeletal maturation, total daily HC dose, and exposure over the first 4 years of life. Results No significant differences were found in height, weight, or body mass index z-scores at 4 years, and in predicted adult height, before or after adjusting for age at diagnosis and sex. Bone age z-scores averaged 2.8 SDs lower for patients on HC suspension compared with HC tablets (P < 0.001) after adjusting for age at diagnosis and sex. The suspension group received 30.4% lower (P > 0.001) average cumulative HC doses by their fourth birthday. Conclusions Our data indicate that treatment with alcohol-free HC suspension decreased androgen exposure as shown by lower bone age z-scores, allowed lower average and cumulative daily HC dose compared to HC tablets, and generated no significant differences in SDS in growth parameters in children with CAH at 4 years of age. Longitudinal studies of treating with smaller HC doses during childhood are needed.
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Affiliation(s)
- Heba Al-Rayess
- Division of Endocrinology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55454, USA
| | - O Yaw Addo
- Department of Global Health, Rollins School of Emory University, Atlanta, GA 30322, USA
| | - Elise Palzer
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN 55455, USA
| | - Mu'taz Jaber
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
| | - Kristin Fleissner
- Division of Endocrinology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55454, USA
| | - James Hodges
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN 55455, USA
| | - Richard Brundage
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
| | - Bradley S Miller
- Division of Endocrinology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55454, USA
| | - Kyriakie Sarafoglou
- Division of Endocrinology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55454, USA.,Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
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Pitsava G, Stratakis CA. Adrenal hyperplasias in childhood: An update. Front Endocrinol (Lausanne) 2022; 13:937793. [PMID: 35992119 PMCID: PMC9382287 DOI: 10.3389/fendo.2022.937793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Pediatric adrenocortical hyperplasias are rare; they usually present with Cushing syndrome (CS); of them, isolated micronodular adrenal disease and its variant, primary pigmented adrenocortical disease are the most commonly encountered. Most cases are due to defects in the cyclic AMP/protein kinase A (cAMP/PKA) pathway, although a few cases remain without an identified genetic defect. Another cause of adrenal hyperplasia in childhood is congenital adrenal hyperplasia, a group of autosomal recessive disorders that affect steroidogenic enzymes in the adrenal cortex. Clinical presentation varies and depends on the extent of the underlying enzymatic defect. The most common form is due to 21-hydroxylase deficiency; it accounts for more than 90% of the cases. In this article, we discuss the genetic etiology of adrenal hyperplasias in childhood.
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Affiliation(s)
- Georgia Pitsava
- Division of Intramural Research, Division of Population Health Research, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Georgia Pitsava,
| | - Constantine A. Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- Human Genetics and Precision Medicine, Institute of Molecular Biology and Biotechnology of the Foundation for Research and Technology Hellas (IMBB-FORTH), Heraklion, Greece
- ELPEN Research Institute, ELPEN, Athens, Greece
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Dubinski I, Bechtold Dalla-Pozza S, Bidlingmaier M, Reisch N, Schmidt H. Reverse circadian glucocorticoid treatment in prepubertal children with congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 2021; 34:1543-1548. [PMID: 34523293 DOI: 10.1515/jpem-2021-0540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/03/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Children with salt-wasting congenital adrenal hyperplasia (CAH) have an impaired function of steroid synthesis pathways. They require therapy with glucocorticoid (GC) and mineralocorticoid hormones to avoid salt-wasting crisis and other complications. Most commonly, children receive hydrocortisone thrice daily with the highest dose in the morning, mimicking the regular physiology. However, reverse circadian treatment (RCT) had been suggested previously. In this study, we aimed to determine the efficacy of RCT in prepubertal children with CAH by comparing the salivary 17-hydroxyprogesterone (s17-OHP) levels individually. METHODS In this retrospective study, we analyzed the records of children with classical CAH and RCT who were monitored by s17-OHP levels. The study included 23 patients. We identified nine prepubertal children with RCT schemes (three boys and six girls) and compared the s17-OHP levels in the morning, afternoon, and evening. The objective of this study was to demonstrate the non-effectiveness of RCT in terms of lowering the morning s17-OHP concentration. In addition, we compared s17-OHP day profiles in six patients on RCT and non-RCT therapy (intraindividually). RESULTS Eight of nine children with RCT showed higher s17-OHP levels in the morning compared to the evening. In addition, none of the children showed a significant deviation of development. Three children were overweight. No adrenal crisis or pubertal development occurred. Comparison of RCT and non-RCT regimens showed no difference in 17-OHP profiles. CONCLUSIONS Our data do not support the use of RCT schemes for GC replacement in children with CAH due to lack of benefits and unknown long-term risks.
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Affiliation(s)
- Ilja Dubinski
- Division for Pediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Susanne Bechtold Dalla-Pozza
- Division for Pediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | | | - Nicole Reisch
- Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Heinrich Schmidt
- Division for Pediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
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Glukokortikoide bei nichtendokrinen Erkrankungen, bei Kortisolmangel und bei endogenem Exzess – der Einfluss therapeutischer Strategien auf das kindliche Wachstum. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-019-0697-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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12
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Wasniewska MG, Morabito LA, Baronio F, Einaudi S, Salerno M, Bizzarri C, Russo G, Chiarito M, Grandone A, Guazzarotti L, Spinuzza A, Corica D, Ortolano R, Balsamo A, Abrigo E, Baldini Ferroli B, Alibrandi A, Capalbo D, Aversa T, Faienza MF. Growth Trajectory and Adult Height in Children with Nonclassical Congenital Adrenal Hyperplasia. Horm Res Paediatr 2021; 93:173-181. [PMID: 32810858 DOI: 10.1159/000509548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 06/16/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Children with nonclassical congenital adrenal hyperplasia (NCCAH) often present increased growth velocity secondary to elevation of adrenal androgens that accelerates bone maturation and might compromise adult height (AH). OBJECTIVE The aim of the study was to analyze prognostic factors affecting growth trajectory (GT) and AH in children with NCCAH. METHODS The study was a retrospective, multicentric study. The study population consisted of 192 children with a confirmed molecular diagnosis of NCCAH, followed by pediatric endocrinology centers from diagnosis up to AH. Clinical records were collected and analyzed. AH (standard deviation score; SDS), pubertal growth (PG) (cm), GT from diagnosis to AH (SDS), and AH adjusted to target height (TH) (AH-TH SDS) were evaluated as outcome indicators using stepwise linear regression models. RESULTS The stepwise linear regression analysis showed that AH and AH-TH were significantly related to chronological age (CA) (p = 0.008 and 0.016), bone age (BA)/CA ratio (p = 0.004 and 0.001), height (H) (p < 0.001 for both parameters) at NCCAH diagnosis, and TH (p = 0.013 and <0.001). PG was higher in males than in females (22.59 ± 5.74 vs. 20.72 ± 17.4 cm, p = 0.002), as physiologically observed, and was positively related to height (p = 0.027), negatively to BMI (p = 0.001) and BA/CA ratio (p = 0.001) at NCCAH diagnosis. Gender, genotype, biochemical data, and hydrocortisone treatment did not significantly impair height outcomes of these NCCAH children. CONCLUSIONS The results of this study suggest that AH and GT of NCCAH patients are mainly affected by the severity of phenotype (CA, BA/CA ratio, and H) at the time of diagnosis.
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Affiliation(s)
- Malgorzata Gabriela Wasniewska
- Department of Human Pathology of Adulthood and Childhood Gaetano Barresi, Gaetano Martino University Hospital, University of Messina, Messina, Italy,
| | - Letteria Anna Morabito
- Department of Human Pathology of Adulthood and Childhood Gaetano Barresi, Gaetano Martino University Hospital, University of Messina, Messina, Italy
| | - Federico Baronio
- Department of Women, Children and Urological Diseases, S. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Silvia Einaudi
- Department of Pediatric Endocrinology and Diabetology, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Mariacarolina Salerno
- Pediatric Endocrine Unit, Department of Translational Medical Sciences, Pediatrica Section, Federico II University of Naples, Naples, Italy
| | - Carla Bizzarri
- Endocrinology and Diabetes Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Gianni Russo
- Department of Pediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Mariangela Chiarito
- Department of Biomedical Sciences and Human Oncology, Pediatric Section, University of Bari "A. Moro", Bari, Italy
| | - Anna Grandone
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Antonietta Spinuzza
- Department of Human Pathology of Adulthood and Childhood Gaetano Barresi, Gaetano Martino University Hospital, University of Messina, Messina, Italy
| | - Domenico Corica
- Department of Human Pathology of Adulthood and Childhood Gaetano Barresi, Gaetano Martino University Hospital, University of Messina, Messina, Italy
| | - Rita Ortolano
- Department of Women, Children and Urological Diseases, S. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Antonio Balsamo
- Department of Women, Children and Urological Diseases, S. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Enrica Abrigo
- Department of Pediatric Endocrinology and Diabetology, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | | | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy
| | - Donatella Capalbo
- Pediatric Endocrine Unit, Department of Translational Medical Sciences, Pediatrica Section, Federico II University of Naples, Naples, Italy
| | - Tommaso Aversa
- Department of Human Pathology of Adulthood and Childhood Gaetano Barresi, Gaetano Martino University Hospital, University of Messina, Messina, Italy
| | - Maria Felicia Faienza
- Department of Biomedical Sciences and Human Oncology, Pediatric Section, University of Bari "A. Moro", Bari, Italy
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Kamrath C, Hartmann MF, Pons-Kühnemann J, Wudy SA. Urinary GC-MS steroid metabotyping in treated children with congenital adrenal hyperplasia. Metabolism 2020; 112:154354. [PMID: 32916150 DOI: 10.1016/j.metabol.2020.154354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Treatment of children with classic congenital adrenal hyperplasia (CAH) is a difficult balance between hypercortisolism and hyperandrogenism. Biochemical monitoring of treatment is not well defined. OBJECTIVE Cluster analysis of the urinary steroid metabolome obtained by targeted gas chromatography-mass spectrometry (GC-MS) for treatment monitoring of children with CAH. METHODS We evaluated 24-h urinary steroid metabolome analyses of 109 prepubertal children aged 7.0 ± 1.6 years with classic CAH due to 21-hydroxylase deficiency treated with hydrocortisone and fludrocortisone. 24-h urinary steroid metabolite excretions were transformed into CAH-specific z-scores. Subjects were divided into groups (metabotypes) by k-means clustering algorithm. Urinary steroid metabolome and clinical data of patients of each metabotype were analyzed. RESULTS Four unique metabotypes were generated. Metabotype 1 (N = 21 (19%)) revealed adequate metabolic control with low cortisol metabolites (mean: -0.57z) and suppressed androgen and 17α-hydroxyprogesterone (17OHP) metabolites (-0.79z). Metabotype 2 (N = 23 (21%)) showed overtreatment consisting of a constellation of elevated urinary cortisol metabolites (0.62z) and low metabolites of androgens and 17OHP (-0.75z). Metabotype 3 (N = 32 (29%)) demonstrated undertreated patients with low cortisol metabolites (-0.69z) and elevated metabolites of androgens and 17OHP (0.50z). Metabotype 4 (N = 33 (30%)) presented patients with treatment failure reflected by unsuppressed androgen- and 17OHP metabolites (0.71z) despite elevated urinary cortisol metabolites (0.39z). CONCLUSION Metabotyping, which means grouping metabolically similar individuals, helps to monitor treatment of children with CAH using GC-MS urinary steroid metabolome analysis. This method allows classification in adequately-, over-, or undertreated children as well as identification of patients with treatment failure.
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Affiliation(s)
- Clemens Kamrath
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Michaela F Hartmann
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Jörn Pons-Kühnemann
- Medical Statistics, Institute of Medical Informatics, Justus Liebig University, Giessen, Germany
| | - Stefan A Wudy
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany.
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Ning D, Zhang Z, Qiu K, Lu L, Zhang Q, Zhu Y, Wang R. Efficacy of intelligent diagnosis with a dynamic uncertain causality graph model for rare disorders of sex development. Front Med 2020; 14:498-505. [PMID: 32681210 DOI: 10.1007/s11684-020-0791-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 07/17/2020] [Indexed: 11/26/2022]
Abstract
Disorders of sex development (DSD) are a group of rare complex clinical syndromes with multiple etiologies. Distinguishing the various causes of DSD is quite difficult in clinical practice, even for senior general physicians because of the similar and atypical clinical manifestations of these conditions. In addition, DSD are difficult to diagnose because most primary doctors receive insufficient training for DSD. Delayed diagnoses and misdiagnoses are common for patients with DSD and lead to poor treatment and prognoses. On the basis of the principles and algorithms of dynamic uncertain causality graph (DUCG), a diagnosis model for DSD was jointly constructed by experts on DSD and engineers of artificial intelligence. "Chaining" inference algorithm and weighted logic operation mechanism were applied to guarantee the accuracy and efficiency of diagnostic reasoning under incomplete situations and uncertain information. Verification was performed using 153 selected clinical cases involving nine common DSD-related diseases and three causes other than DSD as the differential diagnosis. The model had an accuracy of 94.1%, which was significantly higher than that of interns and third-year residents. In conclusion, the DUCG model has broad application prospects as a computer-aided diagnostic tool for DSD-related diseases.
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Affiliation(s)
- Dongping Ning
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- Department of Pediatrics, Linfen Central Hospital, Linfen, 041000, China
| | - Zhan Zhang
- Institute of Nuclear and New Energy Technology, Tsinghua University, Beijing, 100084, China
| | - Kun Qiu
- Institute of Nuclear and New Energy Technology, Tsinghua University, Beijing, 100084, China
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Qin Zhang
- Department of Computer Science and Technology, Tsinghua University, Beijing, 100084, China.
| | - Yan Zhu
- Institute of Internet Industry, Tsinghua University, Beijing, 100084, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
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Atay Z, Turan S, Buğdaycı O, Guran T, Bereket A. Restoration of Height after 11 Years of Letrozole Treatment in 11β-Hydroxylase Deficiency. Horm Res Paediatr 2020; 92:203-208. [PMID: 31454824 DOI: 10.1159/000501456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/11/2019] [Indexed: 11/19/2022] Open
Abstract
11β-hydroxylase deficiency (11β-OHD) is the second most common form of congenital adrenal hyperplasia (CAH). Males with 11β-OHD CAH are often diagnosed late with a significantly advanced bone age leading to a poor height prognosis due to early closure of epiphysis. Delaying epiphyseal fusion by treatment of aromatase inhibitors (AIs) might be a useful strategy in patients with very advanced bone ages. However, there are limited data regarding the effect on final height and long-term safety of this approach. We report our experience with 11 years of letrozole treatment and 17 years of follow-up in a boy with 11β-OHD. He presented at 2 years and 11 months of age with a bone age of 13 years (predicted adult height, PAH, 129.5 cm). Letrozole was added after 1 year of glucocorticoid treatment due to no improvement in height prognosis (130 cm), and continued until the age of 14 years and 11 months. He also received GnRH analog treatment at 10 years and 3 months of age for 2.5 years due to central activation of puberty. He reached a final height of 165.2 cm (35.2 cm above his PAH). This long-term treatment with letrozole was associated with changes in vertebral morphology such as vertebral body end-plate changes, Schmorl nodes, and mild protrusions in the intervertebral discs. Testicular volumes, gonadotropins, testosterone, and anti-Müllerian hormone were normal at age 20 years. A spermiogram showed a normal count but impaired sperm motility and morphology. This unique case represents the longest duration of AI treatment reported in CAH and the first case in which letrozole was started before puberty with the final height reported. We conclude that AIs may restore height in selected patients with CAH with very advanced bone age and severely compromised height prognosis.
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Affiliation(s)
- Zeynep Atay
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Istanbul, Turkey, .,Department of Pediatric Endocrinology, Medipol University, Istanbul, Turkey,
| | - Serap Turan
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Istanbul, Turkey
| | - Onur Buğdaycı
- Department of Radiology, Marmara University, Istanbul, Turkey
| | - Tulay Guran
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Istanbul, Turkey
| | - Abdullah Bereket
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Istanbul, Turkey
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16
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Goedegebuure WJ, Hokken-Koelega AC. Aromatase Inhibitor as Treatment for Severely Advanced Bone Age in Congenital Adrenal Hyperplasia: A Case Report. Horm Res Paediatr 2020; 92:209-213. [PMID: 31390647 PMCID: PMC7050682 DOI: 10.1159/000501746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/25/2019] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Treatment with aromatase inhibitors (AI) is a potential novel treatment in patients with congenital adrenal hyperplasia (CAH) and advanced bone age (BA), to increase near adult height (NAH). Not much is known about the efficacy of AI treatment in CAH and how AI treatment will influence the management of corticosteroid treatment. CASE PRESENTATION At the age of 6 years and 3 months, a boy with salt-losing CAH presented with a BA 7 years in advance. Treatment with an AI (exemestane) was initiated to decelerate bone maturation. We continued the standard dosage of corticosteroid treatment. Precocious puberty was treated with 4 years of gonadotropin-releasing hormone agonist, while AI treatment was continued until attainment of NAH. His NAH 177.7 cm (-0.8 SDS) was considerably higher than his predicted adult height of 151.3 cm (-4.6 SDS) at the start of AI treatment. The higher serum androgen levels during AI treatment did not result in short adult stature. DISCUSSION/CONCLUSION This report shows that AI treatment can adequately decelerate bone maturation, causing predicted adult height to increase significantly in patients of CAH with accelerated bone maturation. We suggest continuing the same corticosteroid dosage during AI treatment and accepting higher serum androgen levels.
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Affiliation(s)
- Wesley J. Goedegebuure
- *Wesley J. Goedegebuure, Department of Paediatrics, Subdivision Endocrinology, Erasmus University Medical Centre, Wytemaweg 80, NL–3015 CN Rotterdam (The Netherlands), E-Mail
| | - Anita C.S. Hokken-Koelega
- Department of Paediatrics, Subdivision Endocrinology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Pijnenburg-Kleizen KJ, Thomas CMG, Otten BJ, Roeleveld N, Claahsen-van der Grinten HL. Long-term follow-up of children with classic congenital adrenal hyperplasia: suggestions for age dependent treatment in childhood and puberty. J Pediatr Endocrinol Metab 2019; 32:1055-1063. [PMID: 31573958 DOI: 10.1515/jpem-2019-0006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/17/2019] [Indexed: 11/15/2022]
Abstract
Background In congenital adrenal hyperplasia (CAH), achieving the balance between overtreatment and undertreatment remains challenging. Final height (FH) can serve as a long-term outcome measure. We aimed to identify age-dependent factors that influence FH in CAH patients, resulting in age-specific treatment goals. Methods We retrospectively evaluated longitudinal data of 39 pediatric CAH patients born between 1980 and 1997 from the Radboudumc CAH database. We analyzed height and bone age (BA) at diagnosis or 4 years of age, at the start of puberty and at FH. Height data were corrected for parental height and secular trend. Hydrocortisone (HC) use and salivary steroid concentrations were studied longitudinally throughout childhood and puberty. Results Median FH standard deviation scores (SDSs) corrected for target height SDSs (THSDSs) was -1.63. Median height SDS corrected for THSDS (HSDS-THSDS) decreased from diagnosis/age 4 years to FH in both salt wasting (SW) CAH and simple virilizing (SV) CAH, and in both male and female patients. However, when height was corrected for BA, no height loss occurred from diagnosis/age 4 years to FH in any of the subgroups, while a height gain was seen in SV males. In the combined model analyzing both HC dose and salivary steroid concentrations, in childhood the androstenedione (A) concentration was negatively associated with FH, while in puberty the HC dose was negatively associated with FH. Conclusions In CAH, loss of growth potential already occurs in early childhood. In prepubertal children, exposure to elevated androgens is associated with decreased FH. In puberty, the growth suppressing effects of HC outweigh the negative effects of elevated androgens. Therefore, we suggest different treatment approaches in prepubertal and pubertal patients.
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Affiliation(s)
- Karijn J Pijnenburg-Kleizen
- Department of Pediatric Endocrinology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands, Phone: +0031-24-3614430, Fax: +0031-24-3614427
| | - Chris M G Thomas
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Barto J Otten
- Department of Pediatric Endocrinology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands
| | - Nel Roeleveld
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hedi L Claahsen-van der Grinten
- Department of Pediatric Endocrinology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands
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Ahmed SEAM, Soliman AT, Ramadan MA, Elawwa A, Abugabal AMS, Emam MHA, De Sanctis V. Long-term prednisone versus hydrocortisone treatment in children with classic Congenital Adrenal Hyperplasia (CAH) and a brief review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:360-369. [PMID: 31580328 PMCID: PMC7233741 DOI: 10.23750/abm.v90i3.8732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Debate still exist about the safety of long-term use of prednisone (PD) versus hydrocortisone (HC) for treating children with congenital adrenal hyperplasia -21OH D (CAH). Despite recent developments in congenital adrenal hyperplasia -21OH D (CAH), several issues related to patient growth and final height remain unsolved. Debate still exist about the safety of long-term use of PD versus HC for treating children with CAH. The mechanism by which glucocorticoid therapy interferes with growth is complex and multifactorial. Relatively slight supra-physiologic levels may be enough to blunt growth velocity. An increased risk of developing obesity is another possible consequence of hyper-cortisolism in children with CAH. OBJECTIVES OF THE STUDY To evaluate the anthropometric and biochemical effects of long-term PD versus HC treatment in children with CAH-21OHD. A brief review of the literature is also reported. PATIENTS AND METHODS This retrospective study evaluated linear growth and biochemical data of thirty children with classic CAH (19 females and 11 males), who were on PD (n=22) or HC (n=8) treatment, since their first diagnosis. Clinical data included age, gender, duration of therapy, dose of HC and or equivalent dose of HC in the PD group, blood pressure, height (Ht) and weight. Ht-SDS and BMI were also calculated. Biochemical data included measurement of 17- OH progesterone, cholesterol, triglycerides (TG), HDL, LDL, fasting glucose, and insulin concentrations. HOMA-IR was calculated. Carotid intima-media thickness (CIMT) was measured using high-resolution B-mode ultrasonography. Thirty normal age matched children were used as controls for the anthropometric and CIMT data. RESULTS The age of children and duration of treatment did not differ among the two treatment groups. After a mean of 6 years of treatment, the Ht-SDS and BMI did not differ between the three groups of children. The equivalent hydrocortisone dose of children on prednisone was significantly higher than the dose for the hydrocortisone group. Both systolic and diastolic blood pressures (BP) of children on PD was slightly higher compared to those on hydrocortisone group. However, the BP of the 2 treatment groups was not different compared to control children. Fasting blood glucose, homeostatic model assessment insulin resistance (HOMA-IR), plasma TG, HDL, and cholesterol did not differ among the two treatment groups. LDL levels were significantly higher in the PD group versus the HC group. The mean CIMT did not differ among the two treatment groups but was significantly higher in the treated groups versus controls. There was a significant linear correlation between BMI-SDS and CIMT (r=0.37, p=0.047). CONCLUSIONS Children with CAH-21OHD who were kept on PD therapy for 6.4±2.7 years, since the beginning of diagnosis, have maintained normal linear growth. No difference in BMI, HOMA-IR, or CIMT was detected among the two treated groups. The efficiency, safety and convenience of a single daily dose of PD could be a good and relatively safe alternative to HC for the continuing medical treatment of patients with CAH-21OHD. However, more prospective studies across childhood and adolescence are necessary to draw definitive conclusions.
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Haddad NG, Eugster EA. Peripheral precocious puberty including congenital adrenal hyperplasia: causes, consequences, management and outcomes. Best Pract Res Clin Endocrinol Metab 2019; 33:101273. [PMID: 31027974 DOI: 10.1016/j.beem.2019.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Peripheral precocious puberty results from peripheral production of sex steroids independent of activation of the hypothalamic-pituitary gonadal axis. It is much less common than central precocious puberty. Causes are variable and can be congenital or acquired. In this review, we will discuss the diagnosis and management of the most common etiologies including congenital adrenal hyperplasia, McCune Albright syndrome, familial male-limited precocious puberty, and adrenal and gonadal tumors.
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Affiliation(s)
- Nadine G Haddad
- Riley Hospital for Children, 705 Barnhill Dr, Rm 5960, Indianapolis, IN 46202, USA.
| | - Erica A Eugster
- Riley Hospital for Children, 705 Barnhill Dr, Rm 5960, Indianapolis, IN 46202, USA.
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Meena H, Jana M, Singh V, Kabra M, Jain V. Growth Pattern and Clinical Profile of Indian Children with Classical 21-Hydroxylase Deficiency Congenital Adrenal Hyperplasia on Treatment. Indian J Pediatr 2019; 86:496-502. [PMID: 30697677 DOI: 10.1007/s12098-018-02848-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To prospectively assess the growth parameters in a cohort of children with classical 21-hydroxylase deficiency congenital adrenal hyperplasia, comprehensively profile their clinical data and evaluate the prevalence of testicular adrenal rest tumors among affected boys. METHODS Children with congenital adrenal hyperplasia aged 0-18 y were prospectively followed up for six mo to 2 y (mean follow-up: 17 ± 6 mo). Baseline data were obtained by interviewing parents and from clinic records. Anthropometry, biochemical parameters, X-ray for bone age, and ultrasound scrotum (in boys >5 y) for testicular adrenal rest tumors were performed. RESULTS Among the 81 children (32 boys, 49 girls), two-thirds (57) had salt-wasting and the remaining had simple virilizing type and the mean age at enrolment was 6.2 ± 4.9 y. The overall height standard deviation score was -0.6 (-2.0 to 0.8) with a greater compromise in children in the age groups 0-2 y and > 10 y and those with salt-wasting type. Overall, 25 (31%) children had short stature and 45 (55.6%) had growth velocity below the reference range. Bone age advancement beyond 2 standard deviation score was seen in 46% of children assessed. Testicular adrenal rest tumors were detected in 5 out of 21 boys (23.8%). CONCLUSIONS The auxological pattern observed in this homogenously-managed Indian pediatric cohort with congenital adrenal hyperplasia highlights that infancy and peri-pubertal age groups are the most vulnerable, reiterating the importance of diligent growth monitoring. The high prevalence of testicular adrenal rest tumors merits the incorporation of annual ultrasound in the follow-up protocol of these patients.
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Affiliation(s)
- H Meena
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Manisha Jana
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Madhulika Kabra
- Division of Genetics, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Vandana Jain
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Kamrath C, Wettstaedt L, Hartmann MF, Wudy SA. Height Velocity defined metabolic Control in Children with Congenital Adrenal Hyperplasia using urinary GC-MS Analysis. J Clin Endocrinol Metab 2019; 104:4214-4224. [PMID: 31112272 DOI: 10.1210/jc.2019-00438] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/15/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Treatment of children with classic congenital adrenal hyperplasia (CAH) with glucocorticoids is a difficult balance between hypercortisolism and hyperandrogenism. Biochemical monitoring of treatment is not well defined. Achievement of a normal growth rate is the most important therapeutic goal. METHODS We retrospectively evaluated 123 24-h GC-MS urinary steroid metabolome analyses together with their corresponding one-year height velocity (HV) z-scores in 63 prepubertal children aged 7.2 ± 1.6 years with classic CAH due to 21-hydroxylase deficiency treated with hydrocortisone and fludrocortisone. RESULTS Multivariate linear mixed effects model analysis revealed a positive influence of CAH-specific z-scores of summed urinary androgen metabolites (B= 0.97 ± 0.20, t-value = 4.97, P < 0.0001) and a negative influence of the cortisol metabolite tetrahydrocortisol (B= -1.75 ± 0.79, t-value = -2.20, P = 0.03) on HV z-scores. ROC analysis demonstrated that adrenal androgen excess, defined as HV > 1.5 z, was best determined by a z-score of all urinary androgen metabolites of > 0.512 (accuracy 66.2%, sensitivity 57.1 %, specificity 74.4%, positive prediction values (PPV) 66.7%, negative prediction values (NPV) 65.9%). Tetrahydrocortisol excretion > 1480 µg/ m2 BSA/ d in conjunction with suppressed urinary androgen metabolites < 0.163 z indicated overtreatment, defined as HV < -1.5 z (accuracy 79.6 %, sensitivity 40.0 %, specificity 94.9%, PPV 75.0%, NPV 80.4%). CONCLUSION We could establish target values for urinary steroid metabolite excretions in children with CAH based on their growth rate. Urinary steroid metabolome analysis represents a highly suitable method for monitoring metabolic control in CAH children.
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Affiliation(s)
- Clemens Kamrath
- Division of Pediatric Endocrinology and Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Lisa Wettstaedt
- Division of Pediatric Endocrinology and Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Michaela F Hartmann
- Division of Pediatric Endocrinology and Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Stefan A Wudy
- Division of Pediatric Endocrinology and Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
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Al Shaikh A, AlGhanmi Y, Awidah S, Bahha A, Ahmed ME, Soliman AT. Clinical Patterns and Linear Growth in Children with Congenital Adrenal Hyperplasia, an 11-Year Experience. Indian J Endocrinol Metab 2019; 23:298-306. [PMID: 31641631 PMCID: PMC6683700 DOI: 10.4103/ijem.ijem_99_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE An important goal in treating children with congenital adrenal hyperplasia (CAH) is to achieve a normal final adult height (FH). The aim of this study was to describe the clinical presentations and evaluate linear growth and possible factors affecting it in children with CAH. METHODS This is a retrospective study of 56 patients with CAH followed up in a tertiary center for 11 years. Patient's data including demographics, clinical, anthropometric, and laboratory information at presentation and during follow-up period were collected from medical records. RESULTS Fifty-six children (31 females) with CAH were seen at KAMC-Jeddah over 11-year period and 91% were 21-hydroxylase deficient. Of these, 46.4% had hyponatremia and 28.6% had hyperkalemia (21.4% had hyponatremia and hyperkalemia) at presentation. Positive family history was documented in 53.6%. Ambiguous genitalia were present in 72% of females and the majority required corrective surgery. Males had significantly decreased HtSDS versus females and females had significantly higher body mass index. The HtSDS of children who had had higher 17OHP or salt-losing crisis during treatment was significantly lower than those who had normal 17OHP and those who did not have salt-losing crisis, respectively. CONCLUSION The final height outcome in our patients with CAH treated with glucocorticoids is lower than the population norm. Proper control of the disease clinically and biochemically through strict compliance to medical therapy as well as close clinical and laboratory monitoring is an important key to achieve normal final adult height in these patients. Side effects, including overweight, obesity, and hypertension are true risk associations and need timely diagnosis and early management.
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Affiliation(s)
- Adnan Al Shaikh
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Yasser AlGhanmi
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Saniah Awidah
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Abdullah Bahha
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Mohamed E. Ahmed
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ashraf T. Soliman
- Department of Pediatrics, Division of Endocrinology, University of Alexandria, Egypt
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Maheshwari A, Khadilkar V, Gangodkar P, Khadilkar A. Long-term Growth in Congenital Adrenal Hyperplasia. Indian J Pediatr 2019; 86:154-158. [PMID: 30097840 DOI: 10.1007/s12098-018-2753-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/19/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To retrospectively assess growth of children with congenital adrenal hyperplasia (CAH) with special reference to puberty and to assess longitudinal growth and final height of subset of children with CAH. METHODS A retrospective analysis of 30 children (14 boys) with classic CAH (11 salt wasters, 19 simple virilisers) followed up for a mean duration of 9.9 ± 2.4 y (Study period December 2002 through December 2016) was performed. Height Z scores, target height Z scores, height velocities and laboratory parameters were analysed. RESULTS Children were treated with hydrocortisone in a mean dose of 15.7 ± 3.3 mg/m2/d. Mean 17-hydroxy progesterone in boys and girls were 10.8 ± 6.7 ng/ml and 11.3 ± 9.3 ng/ml respectively. Fifteen children (7 boys) developed central precocious puberty at mean age of 7.6 ± 1.8 y and 13 were treated with GnRH analogues for 3.5 y. Of all patients, 18 (10 girls, 8 boys) reached final height at a mean age of 14.2 ± 1.6 y. Mean final height achieved was 158.0 ± 8.5 cm in boys [target height (TH) -165.5 ± 3.8 cm] and in girls it was 149.9 ± 6.7 cm [target height (TH) 154.7 ± 6.4 cm]. Final height standard deviation scores (SDS) for boys and girls were - 2.06 ± 1.1 (TH-SDS -1.06 ± 0.5) and - 1.47 ± 1.1 (TH-SDS -0.56 ± 1.2) respectively and were not significantly different from target height Z scores (p > 0.05). Growth velocity was attenuated during pubertal years. CONCLUSIONS Monitoring growth and puberty in children with CAH is critical for optimizing final height.
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Affiliation(s)
- Ankita Maheshwari
- Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India
| | - Vaman Khadilkar
- Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India
| | - Priyanka Gangodkar
- Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India
| | - Anuradha Khadilkar
- Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India.
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Macut D, Zdravković V, Bjekić-Macut J, Mastorakos G, Pignatelli D. Metabolic Perspectives for Non-classical Congenital Adrenal Hyperplasia With Relation to the Classical Form of the Disease. Front Endocrinol (Lausanne) 2019; 10:681. [PMID: 31632355 PMCID: PMC6783496 DOI: 10.3389/fendo.2019.00681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 09/19/2019] [Indexed: 12/17/2022] Open
Abstract
Non-classical congenital adrenal hyperplasia (NC-CAH) represents mild form of CAH with the prevalence of 0. 6 to 9% in women with androgen excess. Clinical and hormonal findings in females with NC-CAH are overlapping with other hyperandrogenic entities such as polycystic ovary syndrome hence causing difficulties in diagnostic approach. Metabolic consequences in subjects with NC-CAH are relatively unknown. We are lacking longitudinal follow of these patients regarding natural course of the disease or the therapeutic effects of the different drug regiments. Patients with NC-CAH similarly to those with classical form are characterized with deteriorated cardiovascular risk factors that are probably translated into cardiometabolic diseases and events. An increased preponderance of obesity and insulin resistance in patients with NC-CAH begin at young age could result in increased rates of metabolic sequelae and cardiovascular disease later during adulthood in both sexes. On the other hand, growth disorder was not proven in patients with NC-CAH in comparison to CAH patients of both gender characterized with reduced final adult height. Similarly, decreased bone mineral density and osteoporosis are not constant findings in patients with NC-CAH and could depend on the sex, and type or dose of corticosteroids applied. It could be concluded that NC-CAH represent a particular form of CAH that is characterized with specificities in clinical presentation, diagnosis, therapeutic approach and metabolic outcomes.
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Affiliation(s)
- Djuro Macut
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Djuro Macut
| | - Vera Zdravković
- Division of Endocrinology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelica Bjekić-Macut
- Department of Endocrinology, UMC Bežanijska kosa, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - George Mastorakos
- Unit of Endocrine Diseases, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Duarte Pignatelli
- Faculty of Medicine, Instituto de Patologia e Imunologia Molecular da Universidade do Porto/I3S Research Institute, Hospital S João, University of Porto, Porto, Portugal
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Alzanbagi MA, Milyani AA, Al-Agha AE. Growth characteristics in children with congenital adrenal hyperplasia. Saudi Med J 2018; 39:674-678. [PMID: 29968889 PMCID: PMC6146245 DOI: 10.15537/smj.2018.7.22193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objectives: To evaluate the growth parameters in congenital adrenal hyperplasia patients in Jeddah, Saudi Arabia. Methods: This is a descriptive retrospective study over the period of 5 years. Data analysis was using Statistical Package for Social Science. The study included 90 participants in which 61 were girls and 29 were boys aged 0 to 18 years . They were evaluated in Pediatric Endocrinology Clinic at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, between January 2012 and January 2017. Results: A total of 90 subjects, of which 67.8% were females and 32.2% were males. Subjects who were underweight constituted 19.1% of the population, while those who were obese were estimated up to 17.6% of the population. Of the children, 25.7% were suffering from short stature and 74.3% had normal height. Approximately 11.8% of the children who suffered from short stature also suffered from hypothyroidism. Mid-parental height of those who suffered from short stature is 159.8 cm. Conclusion: This study showed a significant effect of congenital adrenal hyperplasia on both height, weight, and body mass index. Risk factors includes glucocorticoids dosage, compliance to treatment, and regular follow up. Personalized treatment approach should be followed with all patients diagnosed with congenital adrenal hyperplasia as well as close monitoring and targeted therapy.
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Affiliation(s)
- Mashael A Alzanbagi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. E-mail.
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Meng X, Yu Y. NONCLASSICAL 21-HYDROXYLASE DEFICIENCY PRESENTED AS ADDISON'S DISEASE AND BILATERAL ADRENAL INCIDENTALOMAS. ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:232-236. [PMID: 31149180 DOI: 10.4183/aeb.2017.232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background 21-hydroxylase deficiency (21 OHD) is the most common form of congenital adrenal hyperplasia (CAH) and it has been widely described in the literature. Adrenocortical incidentalomas are unfrequently the presenting manifestations of CAH, especially in nonclassical form of 21 OHD (NC 21 OHD). Myelolipoma has previously been reported more frequently than other adrenal adenomas associated with CAH. Case We report a 40-year old male case of NC 21 OHD with hypoadrenocorticism after unilateral adrenalectomy of the right side because of a large solid incidentaloma (5×4×4cm3) at the age of 31. This patient began to suffer from obvious symptoms of adrenal insufficiency after 9 years from the surgery. He was reviewed and a very low-density adrenal mass (4.1×3.9cm) was found on computed tomography of the abdomen. After he was admitted to our hospital, this patient was confirmed with NC 21 OHD and presented low level cortisol, striking elevated ACTH, aldosterone insufficiency, increased 17-hydroxyprogesterone, progesterone, decreasing androgens and azoospermatism. Conclusion Patients with 21 OHD could be on risk not only for adrenal hyperplasia, but also to develop adrenal adenomas, particularly if the disease was poorly controlled.
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Affiliation(s)
- X Meng
- West China Hospital, Sichuan University, Sichuan, China
| | - Y Yu
- West China Hospital, Sichuan University, Sichuan, China
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Choi JH, Yoo HW. Management issues of congenital adrenal hyperplasia during the transition from pediatric to adult care. KOREAN JOURNAL OF PEDIATRICS 2017; 60:31-37. [PMID: 28289431 PMCID: PMC5346506 DOI: 10.3345/kjp.2017.60.2.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/21/2016] [Accepted: 02/13/2016] [Indexed: 11/27/2022]
Abstract
Steroid 21-hydroxylase deficiency is the most prevalent form of congenital adrenal hyperplasia (CAH), accounting for approximately 95% of cases. With the advent of newborn screening and hormone replacement therapy, most children with CAH survive into adulthood. Adolescents and adults with CAH experience a number of complications, including short stature, obesity, infertility, tumor, osteoporosis, and reduced quality of life. Transition from pediatric to adult care and management of long-term complications are challenging for both patients and health-care providers. Psychosocial issues frequently affect adherence to glucocorticoid treatment. Therefore, the safe transition of adolescents to adult care requires regular follow-up of patients by a multidisciplinary team including pediatric and adult endocrinologists. The major goals for management of adults with 21-hydroxylase deficiency are to minimize the long-term complications of glucocorticoid therapy, reduce hyperandrogenism, prevent adrenal or testicular adrenal rest tumors, maintain fertility, and improve quality of life. Optimized medical or surgical treatment strategies should be developed through coordinated care, both during transition periods and throughout patients' lifetimes. This review will summarize current knowledge on the management of adults with CAH, and suggested appropriate approaches to the transition from pediatric to adult care.
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Affiliation(s)
- Jin-Ho Choi
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Bizzarri C, Improda N, Maggioli C, Capalbo D, Roma S, Porzio O, Salerno M, Cappa M. HYDROCORTISONE THERAPY AND GROWTH TRAJECTORY IN CHILDREN WITH CLASSICAL CONGENITAL ADRENAL HYPERPLASIA. Endocr Pract 2017; 23:546-556. [PMID: 28225306 DOI: 10.4158/ep171751.or] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Poor linear growth is one of the main concerns in children with congenital adrenal hyperplasia (CAH). We aimed to analyze factors affecting growth trajectory in children with classical CAH. METHODS Clinical records of children followed from infancy up to the end of growth at two Italian tertiary referral hospitals were reviewed. Fifty-seven patients (31 males), treated with hydrocortisone and fludrocortisone only, were included. Clinical observations were divided into three groups: 0 to 2 years, 172 observations; from 2 years to puberty onset, 813 observations; after puberty onset, 527 observations. Height velocity, pubertal growth spurt, and final height were evaluated as outcomes. RESULTS Final height standard deviation score (SDS) was lower than target height SDS (-0.74 ± 1.1 versus -0.31 ± 1.01; P<.001). Target-adjusted final height SDS was -0.44 ± 1.8 in males and -0.13 ± 1.1 in females (P = .001). Total pubertal growth was 21.9 ± 7.3 cm in males and 19.2 ± 8.2 cm in females (P = .19). Hydrocortisone dose increased and height-velocity SDS decreased during puberty. At multivariable analysis, height-velocity SDS was adversely affected by hydrocortisone dose (P = .038) and directly related to adrenocorticotropic hormone (ACTH) levels (P = .023). Target-adjusted final-height SDS was adversely affected by hydrocortisone dose (P<.001) and positively related to mineralocorticoid therapy (P = .001) and ACTH levels (P = .02). Total pubertal growth (cm) was positively related to ACTH levels (P = .01). CONCLUSION Height outcome of CAH patients is now better than previously reported. During puberty, the lowest effective dose of hydrocortisone should be used to optimize pubertal growth spurt and final height. ABBREVIATIONS 17-OHP = 17-alpha-hydroxyprogesterone ACTH = adrenocorticotropic hormone BMI = body mass index CAH = congenital adrenal hyperplasia GH = growth hormone HPA = hypothalamus-pituitary-adrenal PRA = plasma renin activity SDS = standard deviation score SV = simple virilizing SW = salt-wasting.
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Bulsari K, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Endocrine 2017; 55:19-36. [PMID: 27928728 DOI: 10.1007/s12020-016-1189-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency is a rare autosomal recessive genetic disorder. It is caused by reduced or absent activity of 11β-hydroxylase (CYP11B1) enzyme and the resultant defects in adrenal steroidogenesis. The most common clinical features of 11 beta-hydroxylase deficiency are ambiguous genitalia, accelerated skeletal maturation and resultant short stature, peripheral precocious puberty and hyporeninemic hypokalemic hypertension. The biochemical diagnosis is based on raised serum 11-deoxycortisol and 11-deoxycorticosterone levels together with increased adrenal androgens. More than 100 mutations in CYP11B1 gene have been reported to date. The level of in-vivo activity of CYP11B1 relates to the degree of severity of 11 beta-hydroxylase deficiency. Clinical management of 11 beta-hydroxylase deficiency can pose a challenge to maintain adequate glucocorticoid dosing to suppress adrenal androgen excess while avoiding glucocorticoid-induced side effects. The long-term outcomes of clinical and surgical management are not well studied. This review article aims to collate the current available data about 11 beta-hydroxylase deficiency and its management.
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Affiliation(s)
- Krupali Bulsari
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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Kamrath C, Wettstaedt L, Boettcher C, Hartmann MF, Wudy SA. The urinary steroidome of treated children with classic 21-hydroxylase deficiency. J Steroid Biochem Mol Biol 2017; 165:396-406. [PMID: 27544322 DOI: 10.1016/j.jsbmb.2016.08.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/11/2016] [Accepted: 08/15/2016] [Indexed: 11/22/2022]
Abstract
Monitoring treatment of children with classic congenital adrenal hyperplasia (CAH) is difficult and biochemical targets are not well defined. We retrospectively analysed 576 daily urinary steroid hormone metabolite profiles determined by gas chromatography-mass spectrometry of 150 children aged 3.0-17.9 years with classic 21-hydroxylase deficiency (21-OHD) on hydrocortisone and fludrocortisone treatment. Daily urinary excretion of glucocorticoid-, 17α-hydroxyprogesterone (17-OHP)-, and androgen metabolites as well as growth and weight gain are presented. Children with classic CAH exhibited increased height velocity during prepubertal age, which was then followed by diminished growth velocity during pubertal age until final height was reached. Final height was clearly below the population mean. 11β-Hydroxyandrosterone was the dominant urinary adrenal-derived androgen metabolite in CAH children. Adrenarche is blunted in children with CAH under hydrocortisone treatment and androgen metabolites except 11β-hydroxyandrosterone were suppressed. Cortisol metabolite excretion reflected supraphysiological hydrocortisone treatment dosage, which resulted in higher body-mass-indices in children with CAH. Reference values of daily urinary steroid metabolite excretions of treated children with CAH allow the clinician to adequately classify the individual patient regarding the androgen-, 17-OHP-, and glucocorticoid status in the context of the underlying disorder. Additionally, urinary 21-OHD-specific reference ranges will be important for research studies in children with CAH.
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Affiliation(s)
- Clemens Kamrath
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Lisa Wettstaedt
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Claudia Boettcher
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Michaela F Hartmann
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany.
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Parsa AA, New MI. Steroid 21-hydroxylase deficiency in congenital adrenal hyperplasia. J Steroid Biochem Mol Biol 2017; 165:2-11. [PMID: 27380651 DOI: 10.1016/j.jsbmb.2016.06.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 02/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) refers to a group of inherited genetic disorders involving deficiencies in enzymes that convert cholesterol to cortisol within the adrenal cortex. There are five key enzymes involved in the production of cortisol. Of these key enzymes, deficiency of 21-hydroxylase is the most commonly defective enzyme leading to CAH representing more than 90% of cases. The low adrenal cortisol levels associated with CAH affects the hypothalamic-pituitary-adrenal negative feedback system leading to increased pituitary adrenocorticotropic hormone (ACTH) production, which overstimulates the adrenal cortex in an attempt to increase cortisol production resulting in a hyperplastic adrenal cortex. The deficiency of enzyme 21-hydroxylase results from mutations or deletions in the CYP21A2 gene found on chromosome 6p. The disorder is transmitted as an autosomal recessive pattern and specific mutations may be correlated to enzymatic compromise of varying degrees, leading to the clinical manifestation of 21-hydroxylase deficiency (21-OHD) CAH.
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Affiliation(s)
- Alan A Parsa
- Department of Medicine, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii, United States.
| | - Maria I New
- Adrenal Steroid Disorders Program, Icahn School of Medicine at Mount Sinai, Manhattan, NY, United States
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Juan L, Huamei M, Zhe S, Yanhong L, Hongshan C, Qiuli C, Jun Z, Song G, Minlian D. Near-final height in 82 Chinese patients with congenital adrenal hyperplasia due to classic 21-hydroxylase deficiency: a single-center study from China. J Pediatr Endocrinol Metab 2016; 29:841-8. [PMID: 27054598 DOI: 10.1515/jpem-2015-0406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/22/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The objective of this study was to identify variables that might interfere with reaching the near final height (NFH) in Congenital adrenal hyperplasia (CAH) due to classic 21-hydroxylase deficiency (21-OHD). METHODS A cross-sectional study of 82 (24 males and 58 females) classic (23 salt-wasting form [SW] and 59 simple-virilizing form [SV]) CAH 21-OHD patients seen in our institution between 1989 and 2015 with 10.6 (0.5~25.5) years of follow-up who reached their NFH was conducted. The variables related to NFH were explored. RESULTS NFH (153.35±8.31) cm, (-1.9±1.1) SD was significantly lower than the normal population (p<0.001). The treated patients reached a significantly higher NFH (-1.7±1.1) SD than those untreated (-2.6±1.0) SD (p<0.05). Both of early treatment and late treatment group were taller than untreated group (p<0.001, p=0.013, respectively), and early treatment group had a taller height trend than late treatment group (p=0.089). A better height outcome was observed in patients with advantage in target height, good compliance, and low hydrocortisone dose by multivariate Cox regression analysis in 62 treatment patients. NFH and hydrocortisone dose was negatively correlated (r=-0.23, p=0.078) in treated group. Patients complicated by central precocious puberty (CPP) received gonadotropin-releasing hormone analogue (GnRHa) plus letrozole had increased NFH with height SD for bone age and Ht SD improved after treatment compare to no intervention group (p=0.001, p=0.035). CONCLUSIONS Patients with classic 21-OHD have blunted final height, as compared with their target height and the population norm, not-treated even worse. Careful treatment adjustments have a favorable influence on growth. Alternative treatments, such as the use of puberty inhibitors GnRHa in addition to anti-estrogen therapy letrozole can somewhat improve NFH in children with 21-OHD complicated by CPP.
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MESH Headings
- Adolescent
- Adrenal Hyperplasia, Congenital/ethnology
- Adrenal Hyperplasia, Congenital/physiopathology
- Adrenal Hyperplasia, Congenital/therapy
- Body Height/ethnology
- Child
- Child, Preschool
- China
- Cohort Studies
- Combined Modality Therapy
- Cross-Sectional Studies
- Female
- Follow-Up Studies
- Growth Disorders/ethnology
- Growth Disorders/etiology
- Growth Disorders/physiopathology
- Growth Disorders/prevention & control
- Hospitals, University
- Humans
- Infant
- Infant, Newborn
- Male
- Outpatient Clinics, Hospital
- Proportional Hazards Models
- Puberty, Precocious/ethnology
- Puberty, Precocious/etiology
- Puberty, Precocious/physiopathology
- Puberty, Precocious/prevention & control
- Retrospective Studies
- Severity of Illness Index
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Ghanei A, Mohammadzade G, Zarepur E, Soheilikhah S. Congenital adrenal hyperplasia and vanishing testis: rare case of male pseudohermaphroditism. Int J Reprod Biomed 2016. [DOI: 10.29252/ijrm.14.3.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Khan KM, Gonzalez-Bolanos MT, Holm T, Miller BS, Sarafoglou K. Use of Automated Bone Age for Critical Growth Assessment. Clin Pediatr (Phila) 2015; 54:1038-43. [PMID: 25669921 DOI: 10.1177/0009922815572076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We compared the variability of bone age (BA) rating between clinicians and an automated system in children with congenital adrenal hyperplasia (CAH). METHOD A total of 126 radiographs assessed by 3 clinicians blinded to patient details using Greulich and Pyle (GP) (readers 1, 2, and 3) and BoneXpert (BX). RESULTS Comparing BA rating with each other, the mean of the absolute differences varied from 0.42 ± 0.53 years (reader 1 and BX) to 0.57 ± 0.58 years (reader 2 and reader 3), P = .368. Comparing ratings that were consistent with all 4 methods (within 1 year of each other, 93/126, 74%) and the remaining, "outliers" (33/126, 26%), the outliers were younger (P = .003), smaller (height, P = .011, weight, P = .000), and prepubertal (P = .001). CONCLUSION The variability of BA rating in CAH children is similar whether performed by clinicians or an automated system. The greatest variability was in prepubertal children.
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Affiliation(s)
- Khalid M Khan
- MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Tara Holm
- University of Minnesota, Minneapolis, MN, USA
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36
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Eugster EA. The Use of Gonadotropin-Releasing Hormone Analogs beyond Precocious Puberty. J Pediatr 2015; 167:481-5. [PMID: 26073104 DOI: 10.1016/j.jpeds.2015.05.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/21/2015] [Accepted: 05/18/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Erica A Eugster
- Department of Pediatrics, Section of Pediatric Endocrinology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN.
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The relation of peripubertal and pubertal growth to final adult height in children with classic congenital adrenal hyperplasia. J Pediatr 2015; 166:743-50. [PMID: 25557963 DOI: 10.1016/j.jpeds.2014.11.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/15/2014] [Accepted: 11/11/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To determine the relationships between peripubertal and pubertal timing and growth, along with glucocorticoid exposure, to the reduced final adult height seen in patients with congenital adrenal hyperplasia (CAH). STUDY DESIGN Chart review of 104 children with classic CAH (41 males: 28 salt-wasting, 13 simple-virilizing; 63 females: 38 salt-wasting, 25 simple-virilizing) were selected from a cohort from 3 medical institutions in Minnesota. Triple logistic modeling of longitudinal data was performed to determine patterns of peripubertal and pubertal growth. RESULTS Hydrocortisone dose was similar between subtypes and during all growth periods. Simple-virilizing boys (P < .01) and girls (P < .01) were diagnosed later than their salt-wasting counterparts. Height at take-off SDS was reduced for patients with salt-wasting (boys: P < .01; girls: P < .01), and bone age at take-off SDS was more advanced for patients with simple-virilizing (boys: P < .01; girls: P = .05). Bone age at pubertal onset SDS was advanced for all patients, but more so for boys and girls with simple-virilizing. Although all patients had reduced final adult height SDS, this was more pronounced in patients with salt-wasting. CONCLUSION Reduced final adult height SDS in patients with salt-wasting vs simple-virilizing may be attributable in part to a later age of diagnosis and resultant less prolonged exposure to hydrocortisone. This finding suggests that duration of hydrocortisone treatment in the peripubertal period, independent of the hydrocortisone dose, may affect final adult height in patients with CAH.
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Han TS, Conway GS, Willis DS, Krone N, Rees DA, Stimson RH, Arlt W, Walker BR, Ross RJ. Relationship between final height and health outcomes in adults with congenital adrenal hyperplasia: United Kingdom congenital adrenal hyperplasia adult study executive (CaHASE). J Clin Endocrinol Metab 2014; 99:E1547-55. [PMID: 24878054 DOI: 10.1210/jc.2014-1486] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Treatment of congenital adrenal hyperplasia (CAH) in childhood focuses on growth and development and adult final height (FH) is a measure of effective treatment. We hypothesized that shorter adults will have more severe underlying disease and worse health outcomes. METHODS This was a cross-sectional analysis of 199 adults with CAH. FH and quality of life were expressed as z-scores adjusted for midparental target height or UK population height. RESULTS FH correlated inversely with age (men, r = -0.38; women, r = -0.26, P < .01). Men and women had z-scores adjusted for midparental target height of -2 and -1, respectively, and both groups had UK population height z-scores of -1 below the UK population (P < .01). In women, FH was shorter in non-salt-wasting than salt-wasting classic CAH (P < .05) and in moderately affected genotype group B women than either more severely affected groups null and A (P < .01) or the mildest group C (P < .001). Short stature and a higher prevalence of hypertension were observed in classic CAH patients diagnosed late (after 1 y) compared with those diagnosed early and in women treated with glucocorticoid only compared with those treated with both glucocorticoids and mineralocorticoids (P < .05). FH did not associate with insulin sensitivity, lipid profile, adiposity, or quality of life. CONCLUSIONS Adult CAH patients remain short, although height prognosis has improved over time. The shortest adults are those diagnosed late with moderate severity CAH and are at increased risk of adult hypertension; we hypothesize that these patients are exposed in childhood to high androgens and/or excessive glucocorticoids with potential programming of hypertension. Another possibility is inadequate mineralocorticoid treatment early in life in the late-diagnosed patient group. Prospective studies are now required to examine these hypotheses.
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Affiliation(s)
- T S Han
- Department of Endocrinology (T.S.H.), St Peter's National Health Service Foundation Trust, Surrey KT16 0PZ, United Kingdom; Department of Endocrinology (G.S.C.), University College London Hospitals, London W1T 3AA, United Kingdom; Society for Endocrinology (D.S.W.), Bristol BS32 4JT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K., W.A.), School of Clinical and Experimental Medicine, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrine and Diabetes Sciences (D.A.R.), Institute for Molecular and Experimental Medicine, Cardiff University, Cardiff CF10 3US, United Kingdom; Endocrinology Unit (R.H.S., B.R.W.), Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4SB, United Kingdom; and Academic Unit of Diabetes, Endocrinology, and Metabolism (R.J.R.), University of Sheffield, Sheffield S10 2HF, United Kingdom
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Davis P, Edwards L. The new IOC and IAAF policies on female eligibility: old Emperor, new clothes? SPORT, ETHICS AND PHILOSOPHY 2014. [DOI: 10.1080/17511321.2014.899613] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sarafoglou K, Addo OY, Turcotte L, Otten N, Wickremasinghe A, Pittock S, Kyllo J, Lteif AN, Himes JH, Miller BS. Impact of hydrocortisone on adult height in congenital adrenal hyperplasia-the Minnesota cohort. J Pediatr 2014; 164:1141-1146.e1. [PMID: 24560184 DOI: 10.1016/j.jpeds.2014.01.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 12/04/2013] [Accepted: 01/06/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To estimate the impact of the average daily dose of hydrocortisone (HC) on the amount of growth attained in children with congenital adrenal hyperplasia (CAH). The effect of glucocorticoid therapy on adult height (AH) in children with CAH has yet to be elucidated. STUDY DESIGN Triple-logistic models estimating components of growth and maturation were fitted to longitudinal records of 104 patients with classic CAH from 3 pediatric medical centers in Minnesota between 1955 and 2012. A total of 3664 clinical encounters were examined. Random-effects longitudinal models with time-related covariates were used to estimate the effect of HC therapy on linear growth. RESULTS The predicted AH z-score (-0.7) was similar between the sexes and among CAH subtypes. The mean growth period HC dose was 18.9 ± 5.6 mg/m(2)/day. In the final regression model, HC dose was negatively associated with predicted AH, with each mg/m(2)/day increase in average growth period HC dose predicting a 0.37-cm decrease in AH (P < .004). CONCLUSION This study has quantified the fractional reduction in predicted final AH with an incremental increase in HC dose. These findings have important clinical implications in the decision making balance between HC replacement dose and adrenal androgen suppression in children with CAH.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN.
| | - O Yaw Addo
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Lucie Turcotte
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN
| | - Noelle Otten
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN
| | - Andrea Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Siobhan Pittock
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Jennifer Kyllo
- Division of Diabetes and Endocrinology, Children's Hospitals of Minnesota, Minneapolis, MN
| | - Aida N Lteif
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - John H Himes
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Bradley S Miller
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN
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Knowles RL, Khalid JM, Oerton JM, Hindmarsh PC, Kelnar CJ, Dezateux C. Late clinical presentation of congenital adrenal hyperplasia in older children: findings from national paediatric surveillance. Arch Dis Child 2014; 99:30-4. [PMID: 24043550 PMCID: PMC3888619 DOI: 10.1136/archdischild-2012-303070] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To describe the clinical presentation and sequelae, including salt-wasting crises of newly-diagnosed congenital adrenal hyperplasia (CAH) in children aged over 1 year in a contemporary population without screening. To appraise the potential benefit of newborn screening for late-presenting CAH. DESIGN Active national surveillance undertaken in Great Britain prospectively from 2007-2009 through the British Paediatric Surveillance Unit. SETTING England, Wales and Scotland. PATIENTS Children first presenting aged 1-15 years with clinical features of CAH and elevated 17-hydroxyprogesterone. RESULTS Fifty-eight children (26 [45%] boys) aged 1-15 years were reported; 50 (86%) had 21-hydroxylase deficiency. Diagnosis was precipitated by secondary sexual characteristics (n=38 [66%]; median age 5.8 [IQR] 4.8, 7.6) years, genital virilisation (8 girls; 3.2 [IQR 1.3, 7.3] years) or an affected sibling (n=8; 10.0 [IQR 7.4, 13.3] years). At least 33 (57%) children had advanced bone age and 13 (30%) were obese (body mass index ≥ 95 th centile). No child had experienced a salt-wasting crisis. CONCLUSIONS In Great Britain, 30 children aged 1-15 years present annually for the first time with CAH. Older children frequently manifest prematurely advanced epiphyseal and pubertal maturation and genital virilisation, which are often irreversible and likely to have long-lasting consequences for adult health and wellbeing. Almost one-third of affected children are obese before commencing steroid therapy. Newborn screening offers the potential to avoid serious clinical manifestations in older children with unrecognised CAH; however, it may also detect some children who would otherwise remain asymptomatic and for whom the benefit from treatment is uncertain.
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Affiliation(s)
- Rachel L Knowles
- MRC Centre of Epidemiology for Child Health, Institute of Child Health, University College London, London, UK
| | - Javaria M Khalid
- MRC Centre of Epidemiology for Child Health, Institute of Child Health, University College London, London, UK
| | - Juliet M Oerton
- MRC Centre of Epidemiology for Child Health, Institute of Child Health, University College London, London, UK
| | - Peter C Hindmarsh
- London Centre for Paediatric Endocrinology and Metabolism, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | | | - Carol Dezateux
- MRC Centre of Epidemiology for Child Health, Institute of Child Health, University College London, London, UK
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Validation of automatic bone age determination in children with congenital adrenal hyperplasia. Pediatr Radiol 2013; 43:1615-21. [PMID: 24091922 DOI: 10.1007/s00247-013-2744-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 04/06/2013] [Accepted: 04/22/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Determination of bone age is routinely used for following up substitution therapy in congenital adrenal hyperplasia (CAH) but today is a procedure with significant subjectivity. OBJECTIVE The aim was to test the performance of automatic bone age rating by the BoneXpert software package in all radiographs of children with CAH seen at our clinic from 1975 to 2006. MATERIALS AND METHODS Eight hundred and ninety-two left-hand radiographs from 100 children aged 0 to 17 years were presented to a human rater and BoneXpert for bone age rating. Images where ratings differed by more than 1.5 years were each rerated by four human raters. RESULTS Rerating was necessary in 20 images and the rerating result was closer to the BoneXpert result than to the original manual rating in 18/20 (90 %). Bone age rating precision based on the smoothness of longitudinal curves comprising a total of 327 data triplets spanning less than 1.7 years showed BoneXpert to be more precise (P<0.001). CONCLUSION BoneXpert performs reliable bone age ratings in children with CAH.
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Kamoun M, Feki MM, Abid M. Height outcome of patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency: Evidence from recent data. Indian J Endocrinol Metab 2013; 17:543-544. [PMID: 23961467 PMCID: PMC3743351 DOI: 10.4103/2230-8210.113718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Mahdi Kamoun
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Mouna Mnif Feki
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Mohamed Abid
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
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Hassan MM, Ibrahim A, Abdel-Salam A, Huthail H. Growth in infants with congenital adrenal hyperplasia due to 21-hydroxylase deficiency: An analysis of the factors affecting height. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2013. [DOI: 10.1016/j.epag.2013.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Cordeiro GV, Silva IN, Goulart EMA, Chagas AJD, Kater CE. Final height in congenital adrenal hyperplasia: the dilemma of hypercortisolism versus hyperandrogenism. ACTA ACUST UNITED AC 2013; 57:126-31. [DOI: 10.1590/s0004-27302013000200005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 09/22/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: The purpose of this study was to identify factors that might interfere with reaching the final height in patients with 21-hydroxylase deficiency (21-OHD). SUBJECTS AND METHODS: Thirty-one patients with classical 21-OHD who reached their FH in our Institution were evaluated in order to compare the Z score for final height (FHZ) with: (1) the target height, (2) the standard height for the population, and (3) the hydrocortisone treatment schedule. RESULTS: The FHZ of -2.13 ± 1.11 had a significant negative correlation with the hydrocortisone doses used throughout the period of study. Patients who reached FH within the normal population range were those who received lower doses of hydrocortisone, as compared to those whose FH remained below -2 SDS. CONCLUSION: We conclude that careful treatment adjustments have a major influence on growth of children with CAH, and that the dose range for hydrocortisone replacement that does not lead to side effects is relatively narrow. The better height outcome was achieved in 21-OHD patients who received lower doses of hydrocortisone.
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Long-term outcome of patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Am J Med Sci 2012; 344:363-73. [PMID: 22270393 DOI: 10.1097/maj.0b013e31824369e4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder affecting adrenal steroid synthesis. In this study, the authors aim to evaluate the impact of CAH due to 21-hydroxylase deficiency on final height (FH), bone health, cardiometabolic risk, fertility, neurocognition and quality of life in a hospital-based sample from Tunisia. METHODS Twenty-six patients (11 males and 15 females; mean age: 27.4 ± 8.2 years) were recruited. RESULTS Mean FH was 159.5 ± 9.7 cm. Twenty-one patients (80.7%) had a FH below the target height. Ten patients (38.4%) exhibited bone demineralization. Eight patients (30.7%) had obesity. Lipid profile alterations and carbohydrate metabolism disorders were detected in 10 (38.4%) and 5 (19.2%) patients, respectively. Seven patients (27%) had insulin resistance. Ambulatory blood pressure monitoring showed abnormalities in 6 patients (23%). Increased carotid intima-media thickness was found in 14 patients (53.8%). Inhibin B level was decreased in 4 male patients. Semen analysis showed abnormalities in 4 of 10 patients. Testicular tumors were detected in 6 of 11 patients. Anti-Müllerian hormone level was reduced in 4 female patients. Six patients showed poly-cystic ovary syndrome. Brain magnetic resonance imaging showed abnormalities in 11 patients (42.3%). Quality of life was reduced in 14 of 22 patients (63.6%). Many of the suboptimal outcomes appeared to be related to poor adherence to medication schedules, some to overtreatment. CONCLUSION CAH patients have a number of issues due to the disease or its treatment. Regular follow-up, early lifestyle interventions, bone health assessment, testicular ultrasound and psychological management are needed.
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Falhammar H, Thorén M. Clinical outcomes in the management of congenital adrenal hyperplasia. Endocrine 2012; 41:355-73. [PMID: 22228497 DOI: 10.1007/s12020-011-9591-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/20/2011] [Indexed: 01/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of disorders affecting adrenal steroid synthesis. The most common form, 21-hydroxylase deficiency, leads to decreased production of cortisol and aldosterone with increased androgen secretion. In classic CAH glucocorticoid treatment can be life-saving, and provides symptom control, but must be given in an unphysiological manner with the risk of negative long-term outcomes. A late diagnosis or a severe phenotype or genotype has also a negative impact. These factors can result in impaired quality of life (QoL), increased cardiometabolic risk, short stature, osteoporosis and fractures, benign tumors, decreased fertility, and vocal problems. The prognosis has improved during the last decades, thanks to better clinical management and nowadays the most affected patients seem to have a good QoL. Very few patients above the age of 60 years have, however, been studied. Classifying patients according to genotype may give additional useful clinical information. The introduction of neonatal CAH screening may enhance long-term results. Monitoring of different risk factors and negative consequences should be done regularly in an attempt to improve clinical outcomes further.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, D2:04, 17176 Stockholm, Sweden,
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Karkazis K, Jordan-Young R, Davis G, Camporesi S. Out of bounds? A critique of the new policies on hyperandrogenism in elite female athletes. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:3-16. [PMID: 22694023 PMCID: PMC5152729 DOI: 10.1080/15265161.2012.680533] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
In May 2011, more than a decade after the International Association of Athletics Federations (IAAF) and the International Olympic Committee (IOC) abandoned sex testing, they devised new policies in response to the IAAF's treatment of Caster Semenya, the South African runner whose sex was challenged because of her spectacular win and powerful physique that fueled an international frenzy questioning her sex and legitimacy to compete as female. These policies claim that atypically high levels of endogenous testosterone in women (caused by various medical conditions) create an unfair advantage and must be regulated. Against the backdrop of Semenya's case and the scientific and historical complexity of "gender verification" in elite sports, we question the new policies on three grounds: (1) the underlying scientific assumptions; (2) the policymaking process; and (3) the potential to achieve fairness for female athletes. We find the policies in each of these domains significantly flawed and therefore argue they should be withdrawn.
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Affiliation(s)
- Katrina Karkazis
- Stanford Center for Biomedical Ethics, Palo Alto, CA 94305, USA.
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Longui CA, Kochi C, Calliari LEP, Modkovski MBR, Soares M, Alves EF, Prudente FVB, Monte O. Near-final height in patients with congenital adrenal hyperplasia treated with combined therapy using GH and GnRHa. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2011; 55:661-4. [PMID: 22218451 DOI: 10.1590/s0004-27302011000800023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 11/10/2011] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Intrinsic limitations of glucocorticoid therapy in patients with congenital adrenal hyperplasia (CAH) determine frequent loss in final height. The association of secondary central precocious puberty and early epiphyseal fusion is also frequent. In these conditions, GnRHa treatment alone or in combination with GH has been indicated. OBJECTIVES This is a retrospective study, describing the estatural findings of CAH patients with significant decrease in height prediction, who were submitted to combined GH plus GnRHa therapy up to near-final height. SUBJECTS AND METHODS We studied 13 patients, eight females and five males, eight with the classical and five with the nonclassical form of the disorder. Treatment with hydrocortisone (10-20 mg/m(2)/day) or prednisolone (3-6 mg/kg/day) was associated with GnRHa (3.75 mg/months) for 4.0 (1.5) years, and GH (0.05 mg/kg/day) for 3.6 (1.4) years. RESULTS Stature standard deviation score for bone age improved significantly after GH treatment, becoming similar to target height at the end of the second year of GH treatment. CONCLUSION We conclude that combined GH plus GnRHa therapy can be useful in a subset of CAH patients with significant reduction of predicted final height associated with poor hormonal control and central precocious puberty.
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Affiliation(s)
- Carlos Alberto Longui
- Pediatric Endocrinology Unit, Pediatric Department, Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil.
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Abstract
Aromatase, an enzyme located in the endoplasmic reticulum of estrogen-producing cells, catalyzes the rate-limiting step in the conversion of androgens to estrogens in many tissues. The clinical features of patients with defects in CYP19A1, the gene encoding aromatase, have revealed a major role for this enzyme in epiphyseal plate closure, which has promoted interest in the use of inhibitors of aromatase to improve adult height. The availability of the selective aromatase inhibitors letrozole and anastrozole--currently approved as adjuvant therapy for breast cancer--have stimulated off-label use of aromatase inhibitors in pediatrics for the following conditions: hyperestrogenism, such as aromatase excess syndrome, Peutz-Jeghers syndrome, McCune-Albright syndrome and functional follicular ovarian cysts; hyperandrogenism, for example, testotoxicosis (also known as familial male-limited precocious puberty) and congenital adrenal hyperplasia; pubertal gynecomastia; and short stature and/or pubertal delay in boys. Current data suggest that aromatase inhibitors are probably effective in the treatment of patients with aromatase excess syndrome or testotoxicosis, partially effective in Peutz-Jeghers and McCune-Albright syndrome, but probably ineffective in gynecomastia. Insufficient data are available in patients with congenital adrenal hyperplasia or functional ovarian cysts. Although aromatase inhibitors appear effective in increasing adult height of boys with short stature and/or pubertal delay, safety concerns, including vertebral deformities, a decrease in serum HDL cholesterol levels and increase of erythrocytosis, are reasons for caution.
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Affiliation(s)
- Jan M Wit
- Department of Pediatrics, J6S, Leiden University Medical Center, Albinusdreef 2, 2333ZA, P. O. Box 9600, 2300RC Leiden, The Netherlands.
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