Testicular function in prepubertal male pseudohermaphroditism

X-linked congenital adrenal hypoplasia associated with hypospadias in an Egyptian baby: a case report

Introduction

X-linked congenital adrenal hypoplasia is a rare developmental disorder of the human adrenal cortex and is caused by deletion or mutation of the dosage-sensitive sex reversal adrenal hypoplasia congenita critical region of the X chromosome, gene 1 (DAX-1) gene. Most affected children present with failure to thrive, salt wasting and hypoglycemic convulsions in the first months of life. Hypospadias affects approximately one in 250 live male births. Mutations in the mastermind-like domain-containing 1 (MAMLD1) gene have been implicated as one of the causes of hypospadias in children. To the best of our knowledge, an association between congenital adrenal hypoplasia due to a DAX-1 mutation and hypospadias due to mutation of the MAMLD1 gene has not previously been reported in the literature.

Case presentation

A 35-day-old male Egyptian baby was referred to our institution for the evaluation of a two-week history of recurrent vomiting associated with electrolyte imbalance. On examination, our patient was found to have hypotension and dehydration. A genital examination showed distal penile hypospadias with chordee and normal testes. He had hyponatremia, hyperkalemia, hypoglycemia and metabolic acidosis. Endocrinological investigations revealed low levels of cortisol, 17-hydroxyprogesterone and aldosterone, with a high level of adrenocorticotrophic hormone. A provisional diagnosis of congenital adrenal hypoplasia associated with hypospadias was made. A molecular genetics study confirmed the diagnosis of X-linked congenital adrenal hypoplasia due to DAX-1 mutations and hypospadias due to MAMLD1 mutation. He was started on hydrocortisone and fludrocortisone treatment. After three weeks of treatment, his symptoms improved and his blood sugar, sodium, potassium and cortisol levels normalized.

Conclusions

We report the case of an Egyptian baby with an association of congenital adrenal hypoplasia due to DAX-1 mutation and hypospadias due to MAMLD1 mutation. Early diagnosis of this association and determining its optimal treatment are vital in helping to avoid its fatal course.

A missense mutation in the human cytochrome b5 gene causes 46,XY disorder of sex development due to true isolated 17,20 lyase deficiency

CONTEXT

Isolated 17,20 lyase deficiency is commonly defined by apparently normal 17α-hydroxylase activity but severely reduced 17,20 lyase activity of the bifunctional enzyme cytochrome P450 (CYP) enzyme 17A1 (CYP17A1), resulting in sex steroid deficiency but normal glucocorticoid and mineralocorticoid reserve. Cytochrome b5 (CYB5A) is thought to selectively enhance 17,20 lyase activity by facilitating the allosteric interaction of CYP17A1 with its electron donor P450 oxidoreductase (POR).

OBJECTIVE

We investigated a large consanguineous family including three siblings with 46,XY disorder of sex development (DSD) presenting with isolated 17,20 lyase deficiency.

DESIGN

We investigated the clinical and biochemical phenotype, conducted genetic analyses, and functionally characterized the identified CYB5A mutation in cell-based CYP17A1 coexpression assays.

RESULTS

All three siblings presented with 46,XY DSD, sex steroid deficiency, normal mineralocorticoids and glucocorticoids, and a urine steroid metabolome suggestive of isolated 17,20 lyase deficiency. CYP17A1 and POR sequences were normal, but we detected a homozygous CYB5A missense mutation (g.28,400A→T; p.H44L). Functional in vitro analysis revealed normal CYP17A1 17α-hydroxylase activity but severely impaired 17,20 lyase activity. In silico analysis suggested the disruption of CYB5A heme binding by p.H44L.

CONCLUSION

We have identified the first human CYB5A missense mutation as the cause of isolated 17,20 lyase deficiency in three individuals with 46,XY DSD. Detailed review of previously reported cases with apparently isolated 17,20 lyase deficiency due to mutant CYP17A1 and POR reveals impaired 17α-hydroxylase activity as assessed by steroid metabolome analysis and short cosyntropin testing. This suggests that truly isolated 17,20 lyase deficiency is observed only in individuals with inactivating CYB5A mutations.

The syndrome of 17,20 lyase deficiency

CONTEXT

Disorders of steroidogenesis have been instrumental in delineating human steroidogenic pathways. Each genetic disorder seemed to correspond to a different steroidogenic activity, helping to identify several enzymes. Beginning in 1972, several patients have been reported as having "17,20 lyase deficiency," but there have been inconsistent genetic findings.

OBJECTIVE

This manuscript reviews the biochemistry, genetics, and clinical disorders of 17,20 lyase activity, which converts 21-carbon precursors of glucocorticoids to 19-carbon precursors of sex steroids.

FINDINGS

A single enzyme, cytochrome P450c17, catalyzes both 17α-hydroxylase activity and 17,20 lyase activity. The 17,20 lyase activity is especially sensitive to the activities of the accessory proteins P450 oxidoreductase and cytochrome b(5). The first cases of genetically and biochemically proven 17,20 lyase deficiency were reported in 1997, in which specific P450c17 mutations were identified that lost 17,20 lyase activity but not 17α-hydroxylase activity when assayed in vitro. Subsequent work identified other P450c17 mutations and mutations in the genes encoding P450 oxidoreductase and cytochrome b(5). Recently, the initially reported cases from 1972 were found to carry mutations in two aldo-keto reductases, AKR1C2 and AKR1C4. These AKR1C isozymes catalyze 3α-hydroxysteroid dehydrogenase activity in the so-called "backdoor pathway" by which the fetal testis produces dihydrotestosterone without the intermediacy of testosterone.

CONCLUSIONS

17,20 Lyase deficiency should be considered a syndrome with multiple causes, and not a single disease. Study of this very rare disorder has substantially advanced our understanding of the pathways, mechanisms, and control of androgen synthesis. Mutations in other, as-yet unidentified genes may also cause this phenotype.

Cytogenetics and etiology of ambiguous genitalia in 120 pediatric patients

BACKGROUND

A newborn with ambiguous genitalia needs prompt evaluation to detect life-threatening conditions (e.g., salt-losing crisis in congenital adrenal hyperplasia [CAH]) and gender assignment. Sex assignment in these children continues to be a challenging diagnostic and therapeutic problem. We studied the causes and characteristics of ambiguous genitalia in children who were referred to a cytogenetic laboratory.

PATIENTS AND METHODS

We retrospectively reviewed a total of 120 medical records of patients with a primary indication of ambiguous genitalia that were referred to the cytogenetic lab for karyotyping during the period of 1989 to 1999. Diagnosis was based on a clinical impression from the primary physician, who was primarily a staff pediatrician, endocrinologist and/or pediatric urologist.

RESULTS

CAH was the underlying cause of ambiguous genitalia in 41 of 63 patients with ambiguity due to endocrine causes; 39 of these patients showed a 46,XX karyotype and 2 cases were 46,XY (both the 46,XY patients had 3 beta-hydroxylase deficiency). In 57 patients, ambiguous genitalia were due to congenital developmental defects. The most common endocrine case of ambiguous genitalia was 21-OH deficiency. Seven patients were classified as idiopathic with six showing the 46,XY and one the 46,XX karyotype. Gender was reassigned at birth or at diagnosis in 15 patients.

CONCLUSION

The etiology of ambiguous genitalia is variable. The physician managing these families could minimize the trauma of having a child with unidentified sex by providing appropriate genetic counseling so that the parents can make an early decision. Prenatal DNA testing in at-risk families should be considered and appropriate therapy offered to minimize or prevent genital ambiguity.

The testosterone:androstenedione ratio in male undermasculinization

OBJECTIVE

Recent reports suggest that low testosterone:androstenedione (T:A) ratio following hCG stimulation may be a useful method of diagnosing 17beta-hydroxysteroid dehydrogenase-3 (17 betaHSD3) deficiency. The aim of this study was to establish the range of T:A ratios in cases of undermasculinization with proven aetiologies other than 17 betaHSD3.

DESIGN

Register-based study of cases of male undermasculinization reported to a central database by clinicians.

SUBJECTS

Amongst the 421 cases of under-masculinization, 114 cases had testosterone and androstenedione levels before and after hCG stimulation. Of the 114, there were 18 cases of abnormal testes, 17 cases of complete androgen insensitivity syndrome (CAIS), 68 cases of partial AIS (PAIS). Of the 17 cases of CAIS, 13 had evidence of androgen receptor (AR) dysfunction; in the PAIS cohort, 26 cases had evidence of AR dysfunction. Analysis of T:A ratios in the above cohorts and comparison of these ratios to those in a group of previously described cases of 17 betaHSD3 deficiency with a mean ratio of 0.4 (SD: 0.2).

RESULTS

The median age (range) for the CAIS, PAIS and abnormal testes cohort was 1.25 years (0.06-16.5), 0.7 years (0.02-40.3) and 0.5 years (0.04-6.5), respectively. In CAIS, the median T:A rose from 0.4 (0.1 to 8.0) to 4.5 (0.5-16.7); in PAIS, median T:A rose from 0.7 (0.1 to 15) to 3.9 (0.3-20.5); in cases with abnormal testes, median T:A rose from 0.4 (0.1 to 5.6) to 0.6 (0.1-3.6). The median post-hCG T:A ratio was significantly lower in the abnormal testes cohort (P < 0.01). None of the cases of AIS with AR mutation had a low T:A ratio. Only four out of 84 cases diagnosed as AIS had a T:A ratio less than 0.8 (mean + 2SD in 17betaHSD3 deficiency). In one of the four cases, the T:A ratio rose to 3.5 following a prolonged hCG stimulation test.

CONCLUSION

Deficiency of 17betaHSD3 should be considered in 46XY undermasculinization if the post-hCG stimulation T:A ratio is less than 0.8. However, low T:A ratios may be encountered in conditions such as abnormal testes. Before embarking on mutational analysis, we would also recommend careful evaluation for testicular dysgenesis including a prolonged hCG stimulation test in cases with a low T:A ratio.

Regulation of Sertoli cell aromatase activity by cell density and prolonged stimulation with FSH, EGF, insulin and IGF-I at different moments of pubertal development

Sertoli cell aromatase activity is high in very young animals and declines throughout pubertal development. Little is known about the regulatory factors which might be involved in the pronounced decline suffered by this enzymatic activity. In this paper we show that estradiol production in Sertoli cells is dependent on cell density in the culture and that chronic stimulation with hormones can decrease estradiol acute response to FSH. In 8-day-old Sertoli cells cultured at low density (LD: 7.1 +/- 0.3 micrograms DNA), estradiol production was 151 +/- 11 pgE2/micrograms DNA, while in those cultured at high density (HD: 30.3 +/- 0.6 micrograms DNA), production was 30 +/- 5 pgE2/micrograms DNA. Similar results were obtained in 20-day-old Sertoli cell cultures (LD: 57 +/- 4 pgE2/micrograms DNA vs HD: 26.0 +/- 0.6 pgE2/micrograms DNA). On the other hand, treatment of Sertoli cell cultures (8- and 20-day-old) for 96 h, with FSH (100 ng/ml), EGF (50 ng/ml), insulin (10 micrograms/ml) and IGF-I (50 ng/ml) at different densities resulted mostly in inhibition of aromatase activity. The effect caused by FSH was apparently not related to desensitization as aromatization with dbcAMP could not overcome the decreased ability of these cells to produce estradiol. The effect caused by EGF was observed in 8-day-old Sertoli cells cultured under high density conditions. Marked inhibition was observed with insulin and IGF-I in 8-day-old Sertoli cell cultures. Considering previous reports indicating a decrease in Sertoli cell aromatase activity with age, our results suggest a potential role for FSH, EGF, insulin and IGF-I on the Sertoli cell differentiation process which occurs throughout pubertal development.

Hypothalamic-pituitary-gonadal function in prepubertal boys and girls with chronic renal failure

Hypothalamic-pituitary-gonadal function was evaluated in 24 prepubertal children with chronic renal failure (CRF). Among the 17 boys, 5 were receiving conservative treatment and four long-term dialysis. Another eight boys were studied 6 months to 3.3 years after renal transplantation; their ages ranged from 5 years 8 months to 15 1/2 years. Among the girls, two patients were receiving conservative treatment and five long-term dialysis; their ages ranged from 3 1/2 years to 11 years 2 months. In boys with CRF, but not in those after transplantation, mean serum follicle-stimulating hormone 60 minutes after administration of gonadotropin releasing hormone (GnRH) was lower than in 18 control prepubertal boys (mean +/- SD: 2.53 +/- 1.34 vs 6.25 +/- 2.84 IU/L, respectively; p < 0.01). Testosterone steroidogenic capacity after 1 week of stimulation with human chorionic gonadotropin and androgen sensitivity (percentage of decrease of serum sex hormone-binding globulin 1 week after intramuscular administration of testosterone enanthate) were normal. In girls, no difference between those with CRF and a control group of 19 girls was found after intravenous administration of GnRH. However, after intramuscular administration of GnRH agonist, serum follicle-stimulating hormone concentration was lower in girls with CRF than in control girls (p < 0.02); six of seven control girls had an increase of serum estradiol to more than 55 pmol/L, whereas three of seven girls with CRF had no response, and serum follicle-stimulating hormone failed to increase after GnRH agonist therapy in two of these patients. We conclude that hypothalamic-pituitary function is not normal in some prepubertal boys and girls with CRF, particularly in those with low serum albumin concentrations. On the other hand, testicular and ovarian steroidogenic capacity is not impaired, and the biologic response to androgens in boys is preserved.

Surgical approach to male pseudohermaphroditism

Male pseudohermaphroditism (MPH) is defined as incomplete masculinization in patients with normal male karyotype (XY) and testicular histology. MPH encompasses a spectrum of female to male phenotypes and presents both diagnostic and technical challenges to the surgeon. Once gender is assigned, based on phenotype, adequacy of the phallus, and other considerations, the surgeon can plan appropriate genital reconstruction.

High serum sex hormone-binding globulin (SHBG) in premature thelarche

OBJECTIVE

We determined serum sex hormone-binding globulin (SHBG), serum dehydroepiandrosterone sulphate, serum oestradiol and serum testosterone and its fractions in girls with premature thelarche.

DESIGN

Blood was drawn from girls with recently diagnosed (3-12 weeks) premature thelarche. Serum was kept frozen for at least one year before hormonal determination to exclude precocious puberty by clinical evaluation.

PATIENTS

Seventeen girls with premature thelarche aged 0.83-7.16 years were studied, and compared with a group of 22 normal prepubertal girls.

MEASUREMENTS

SHBG was measured by saturation analysis and serum dehydroepiandrosterone sulphate, serum total oestradiol and serum total testosterone were determined by radioimmunoassay. Non-SHBG-bound testosterone and free testosterone were calculated from an equation derived from the law of mass action.

RESULTS

Median serum SHBG in premature thelarche was 137 nmol/l (range 64-221), significantly higher than in normal controls, 93.7 (32-172) (P < 0.05) non-parametric test of medians. Serum SHBG decreased significantly with age in controls but not in premature thelarche. No difference was found in serum dehydroepiandrosterone sulphate. Median serum total testosterone (0.34 nmol/l, 0.17-0.97), median serum non-SHBG-bound testosterone (0.04 nmol/l, 0.02-0.10) and median free testosterone (2.2 pmol/l, 1.0-4.5) were significantly lower in premature thelarche than in control (P < 0.001).

CONCLUSIONS

Serum SHBG is high and bioavailable T is low in girls with premature thelarche. This might alter the oestrogen/androgen ratio in the breast.

Partial 17, 20-desmolase and 17 alpha-hydroxylase deficiencies in a 16-year-old boy

Thirteen plasma steroids as well as ACTH, LH and FSH were measured by specific RIAs under basal and dynamic conditions in a 16-year-old boy (normal external genitalia, 46, XY karyotype) who presented slowness and unachievement of pubertal development. On the delta 4-pathway: basal levels of testosterone and dihydrotestosterone were low- with a normal ratio-, delta 4-androstenedione and 11 beta-hydroxyandrostenedione were in the low normal range. Meanwhile, 17 alpha-hydroxyprogesterone and progesterone levels were markedly elevated. On the delta 5-pathway: dehydroepiandrosterone was extremely low while 17 alpha-hydroxypregnenolone and pregnenolone were almost normal; dehydroepiandrosterone sulfate was subnormal while pregnenolone sulfate was normal. Cortisol, aldosterone were normal while ACTH was moderately increased. Basal and responsive levels of LH and FSH were markedly increased. ACTH stimulation induced a subnormal rise of cortisol and 11 beta-hydroxyandrostenedione, a low or absent rise of dehydroepiandrosterone, 17 alpha-hydroxypregnenolone, androstenedione and 17 alpha-hydroxyprogesterone contrasting with a marked rise of pregnenolone and progesterone. After hCG stimulation, responses were low for testosterone, extremely high for 17 alpha-hydroxyprogesterone with a normalisation of the 17 alpha-hydroxyprogesterone/progesterone ratio. Fluoxymesterone dramatically reduced the pathologically high basal levels of progesterone and 17 alpha hydroxyprogesterone. Dexamethasone induced only a minute decrease in the delta 4-progestagens, a marked decrease in pregnenolone, with a more than 80% reduction of 17 alpha- hydroxypregnenolone, dehydroepiandrosterone, dehydroepiandrosterone sulfate and androstenedione. These data suggest a defect involving the cytochrome P450 common to both 17 alpha-hydroxylase and 17, 20-desmolase activities.(ABSTRACT TRUNCATED AT 250 WORDS)

Validity of the calculation of non-sex hormone-binding globulin-bound estradiol from total testosterone, total estradiol and sex hormone-binding globulin concentrations in human serum

Recent evidences indicate that biologically available serum testosterone (T) and estradiol (E2) include not only the free fractions but also most of the albumin-bound fractions. These two serum T or E2 fractions constitute most of non-sex hormone-binding globulin (SHBG)-bound T or E2, respectively. It has been reported that the estimation of serum non-SHBG-bound T gives identical results when it is assayed experimentally or when it is calculated by a formula derived from the law of mass action assuming two binding systems (T-SHBG and T-albumin). In the present work, we have compared the results of the experimental measurement of non-SHBG-bound E2 with the calculated value derived by an equation based on the law of mass action considering four binding systems (E2-SHBG, T-SHBG, E2-albumin, T-albumin). It was found that the two estimations of non-SHBG-bound E2 correlated closely in normal men (r = 0.80), normal women (r = 0.90) and hirsute women (r = 0.98). When compared with a more complex calculation which includes 21 steroids and 3 binding proteins results also agreed closely. Values for the different T and E2 fractions in these groups of subjects are given. These calculations could be used, not only for clinical research, but also in clinical practice as an useful tool for evaluation of the sex hormone status of patients.

Long-term endocrine sequelae after surgery, radiotherapy, and chemotherapy in children with medulloblastoma

Thirteen children with medulloblastoma, were studied after 2 to 62 months off radiotherapy and chemotherapy with methotrexate and BCNU. Ages at time of study ranged from 2.3 to 15.7 years. Eleven patients, followed for a mean of 22 months, showed a significant decrease of height score, whereas nine patients had deficient growth hormone (GH) response to provocative tests. Clinical pubertal progression was normal in all patients, and three of five girls with advanced pubertal development had menarche. No evidences of gonadotropin disturbances were found in five patients whereas seven had raised basal follicle-stimulating hormone (FSH) level or FSH response to luteinizing hormone-releasing hormone (LH-RH). Abnormalities in thyrotrophin (TSH) secretion were found in 9 of 13 patients. This study shows that poor growth and GH deficiency were frequent in our patients. The high frequency of thyroid disturbances observed point out the need of evaluating thyroid function for adequate replacement therapy. Perhaps modification of adjuvant chemotherapy in the future can diminish drug-induced gonadal damage.

The association of Wilms' tumor, male pseudohermaphroditism and diffuse glomerular disease (Drash syndrome): report of eight cases with clinical and morphologic findings and review of the literature

In 8 children (6 males) at least 2 of 3 disorders were found--male pseudohermaphroditism (MPH), Wilm's tumor, and glomerular disease. MPH was present in the 6 males; they had abdominal cryptorchidism (6/6), ambiguous genitalia (6/6), negative sex chromatin (5/5), and 46XY karyotype (2/2). The gonads examined microscopically in 3 patients were dysgenetic testes. The renal tumor present in 7 was nephroblastoma (NB) of the classical type without anaplasia or nephroblastomatosis, bilateral in 1, and unilateral but multinodular in 2. Five underwent nephrectomy for a renal mass, and in 2 NB was found at open biopsy or at autopsy. The mean age at diagnosis was 10 months. Glomerular disease in 6 patients began with onset of the nephrotic syndrome between 20 days and 39 months of age; it was resistant to steroid therapy and led to death from renal failure. Microscopically the glomerular process was a diffuse mesangial sclerosis (DMS). The 2 children with NB and MPH, but without DMS are healthy 2 1/2 and 9 years postnephrectomy. Neither familial incidence nor parental consanguinity was found. This syndrome has complete and partial forms, and its early recognition is important both for patient management and for assessment of prognosis.

Changes in serum sex hormone-binding globulin and in serum non-sex hormone-binding globulin-bound testosterone during prepuberty in boys

Much evidence suggests that sex hormone-binding globulin (SHBG) influences the delivery of sex steroids to cells, probably by playing an important role in the distribution of serum sex hormones between SHBG-bound, albumin (HSA)-bound and free fractions. Recent evidence also suggests that HSA-bound testosterone (T), the major constituent of non-sex hormone-binding globulin-bound T, is biologically important. To examine the potential exposure of peripheral tissues to T during prepubertal years, the serum concentration of SHBG as well as the distribution of serum T in SHBG-bound, HSA-bound, free and non-SHBG-bound fractions was studied in 80 normal boys aged 0.5-14 yr, all at Tanner's stage G1 of sexual development. A gradual decrease in serum SHBG as a function of age was found without significant changes in the Ka of SHBG-dihydrotestosterone association. While regression analysis of serum total T vs age showed a 2.6-fold increase from 0.5 to 14 yr of age, those of non-SHBG-found, HSA-bound and free T vs age showed 8- to 9-fold increases during the same period. On the other hand, SHBG-bound T had only a 1.9-fold increase. Expressed as a function of serum total T, non-SHBG-bound T increased from 6.6 to 30.4%, the relative increment being greater for HSA-bound T than for free T. It is concluded that, with advancing age, there is a progressive increase in the T exposure of all tissues in normal prepubertal boys. It is speculated that, at the level of the central nervous system, this increase in serum bioavailable T could induce maturative changes in brain cells that result in the onset of puberty in normal boys.

Endocrine and genetic characterization of cousins with male pseudohermaphroditism: evidence that the Lubs phenotype can result from a mutation that alters the structure of the androgen receptor

Impaired virilization of genetic males with testes (male pseudohermaphroditism) can result either from deficiency in androgen production or defects in androgen action, the latter most commonly involving an abnormal androgen receptor. We report here two maternal cousins with male pseudohermaphroditism and clinical features characteristic of the Lubs phenotype, namely apparent females with sufficient fusion of the labioscrotal folds so that a single urogenital sinus orifice is present. Testosterone levels in these genetic males rose appropriately after administration of human chorionic gonadotropin. The amount (maximal binding capacity of 24 to 30 fmol/mg protein) and hormone binding affinity (half-maximal saturation of 0.2 nM) of the androgen receptor in cultured skin fibroblasts was normal, but the receptor was qualitatively abnormal as evidenced by instability on sucrose density gradient centrifugation. The pattern of inheritance in this family is compatible with X-linkage. These findings, together with previous studies, indicate that the spectrum of abnormalities that result from defects of the androgen receptor in genetic men can encompass the entire spectrum between male and female phenotypes.

Endocrine studies in patients with advanced hypospadias

We evaluated 15 boys less than 4 years old with advanced degrees of hypospadias for the presence of an endocrinopathy by a variety of special tests. There were 6 different endocrine-related abnormalities uncovered in 11 patients. One child had been exposed to progesterone given to the mother during the first trimester of pregnancy, 1 had an abnormal karyotype and 1 had an absent gonad on 1 side. One patient with a family history of Reifenstein's syndrome had low receptor numbers and 3 patients exhibited a poor genital response to exogenous testosterone despite normal receptor levels. However, the most striking finding was that of a poor testosterone response to human chorionic gonadotropin injections, which was seen in 7 patients. In several instances this improved with time and even normalized in 2 patients. This experience suggests that hypospadias is a local manifestation of an endocrinopathy rather than a local dysmorphic problem, and that 1 major cause of it may be a delay in maturation of the hypothalamic-pituitary-testicular axis.

17,20-desmolase deficiency in a female newborn, paradoxically virilized in utero

The patient was born with ambiguous genitalia (stade III of Prader). The karyotype revealed a normal female genotype. A defect in 21-hydroxylase, at first suspected, was denied by the hormonal studies. Indeed, extremely high levels of pregnenolone, pregnenolone sulfate, progesterone were found in association with low plasma levels of delta 4-androstenedione, testosterone, dehydroepiandrosterone and its sulfate, while cortisol 17OH-progesterone and ACTH levels and plasma renin activity were normal. The hormonal pattern was thus consistent with 17,20-desmolase deficiency. The dynamic studies further supported this contention: all the progestagens rose further after ACTH stimulation and were suppressed by dexamethasone. Meanwhile, all androgens failed to rise after ACTH: the responses of cortisol were normal. The in utero virilization of the female fetus was not understood until an history of virilization was allegedly found in the mother (luteoma of pregnancy). This is the first case of 17-20 desmolase defect recognized in a female newborn. This child, born with ambiguous genitalia had presented the concurrence of two very rare conditions. The in utero virilization of maternal origin enabled us to make the diagnosis of the 17-20 desmolase defect, which otherwise would have been ignored in a XX subject in the neonatal period because it would obviously be unsymptomatic at this age.

Androgen resistance syndromes

Hereditary defects that impede androgen action cause resistance to the hormone both during embryogenesis and in later life and hence usually cause developmental defects of the male urogenital tract. In genetic males such defects produce a phenotypic spectrum ranging from infertile but otherwise normal men to individuals with varying degrees of ambiguous genitalia to phenotypic women. These disorders can be classified on the basis of the step in androgen action that is impeded by the individual mutations. 5 alpha-Reductase deficiency is an autosomal recessive enzyme defect that impairs the conversion of testosterone to dihydrotestosterone. The internal male genital tract virilizes normally, but the external genitalia are predominantly female in character. The syndrome is the result of one of several mutations that impair the function of the 5 alpha-reductase enzyme. A variety of disorders influence the androgen receptor that mediates the action of both testosterone and dihydrotestosterone. At least four phenotypic variants can be distinguished: complete testicular feminization, incomplete testicular feminization, the Reifenstein syndrome, and the infertile male syndrome, each of which is inherited as an X-linked trait. Absence of receptor binding is found commonly in complete testicular feminization, but qualitative and/or less severe quantitative defects in receptor function can be associated with all four variants. A third type of disorder, receptor positive resistance, also causes variable defects in male development and is associated with normal 5 alpha-reductase activity and normal androgen receptor. The underlying defect is presumed to lie at the intranuclear site or sites of action of the hormone-receptor complex.