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Charoensri S, Auchus RJ. Predictors of Cardiovascular Morbidities in Adults With 21-Hydroxylase Deficiency Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2024; 109:e1133-e1142. [PMID: 37878953 DOI: 10.1210/clinem/dgad628] [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: 08/06/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
CONTEXT The prevalence of cardiovascular and metabolic complications among adults with 21-hydroxylase deficiency (21OHD) is unknown. OBJECTIVE We sought to determine the prevalence of cardiovascular and metabolic morbidities among adults with 21OHD and to identify clinical factors and biomarkers associated with cardiovascular outcomes. METHODS A 10-year retrospective cross-sectional analysis was conducted on adult patients with confirmed 21OHD, aged 18 to 70 years, who had at least one clinical visit for assessment at the University of Michigan. The presence of cardiovascular diseases (CVDs) and other metabolic comorbidities was extracted from medical records based on International Classification of Diseases (ICD) codes. Medical treatments, glucocorticoid (GC) and mineralocorticoid doses, as well as specific biomarkers of disease control since age 18, were collected for analysis. RESULTS A total of 254 patients with 21OHD, median age of 35 years (interquartile range, 28.25-46 y), were included in the analysis. The prevalence of CVDs in the entire cohort was 7.5%. An increase in prevalence was seen from early adulthood, reaching 25% in patients older than 60 years. Increasing age (adjusted odds ratio [OR], 1.05; 95% CI, 1.01-1.09), hypertension (OR, 4.27; 95% CI, 1.41-12.92), and higher GC doses (OR, 1.51; 95% CI, 1.11-2.06) were significantly associated with prevalent CVDs. Higher plasma renin activity was significantly associated with CVDs (OR, 1.07; 95% CI, 1.01-1.15) but not other biochemical markers of disease. CONCLUSION Cardiometabolic morbidities are prevalent among adults with 21OHD. Hypertension, age, and GC exposure are the main predictive factors of established CVDs in our cohort.
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Affiliation(s)
- Suranut Charoensri
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI 48104, USA
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Eyer de Jesus L, Paz de Oliveira AP, Porto LC, Dekermacher S. Testicular adrenal rest tumors - Epidemiology, diagnosis and treatment. J Pediatr Urol 2024; 20:77-87. [PMID: 37845103 DOI: 10.1016/j.jpurol.2023.10.005] [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: 03/12/2023] [Revised: 08/08/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Testicular adrenal rest tumors (TART) are common in males suffering from congenital adrenal hyperplasia (CAH). Correct and timely diagnosis is important for differential diagnosis with malignant testis tumors, related infertility and as TART may worsen in time, especially in the absence of adequate and continuous hormonal control. The rarity of the disease, predominance of small cohorts and case reports and research heterogeneity (concerning type of CAH, patients' age and specific focus of the paper) complicate the understanding of this condition. OBJECTIVES To review epidemiological and clinical aspects of TART, including treatment and prognosis. METHODS Non-systematic review of CAH-related TART research. RESULTS TART's prevalence grows progressively over time, predominating after puberty, affecting a mean of 20-40 % of CAH males. There is no proof of more frequent proportional affection of specific CAH phenotypes or types of enzyme deficiency, but cases of TART among non-classic CAH patients have been rarely reported. Chronic undertreated are more frequently affected and present larger tumors. Systematic ultrasound screening of CAH males is the state-of-the art for diagnosis, but TART are still often diagnosed in CAH adults seeking infertility treatment. TART are usually asymptomatic and present normal testicular volume. Biopsies are not recommended, except when the differential diagnosis between TART and testicular tumors cannot be guaranteed. Abnormal semen analysis is common. Leydig cell tumors are the main differential diagnosis, due to histological similarities to TART. Misdiagnosis may lead to unnecessary orchiectomies. Preservation of gonadal functions is inversely proportional to the total tumor volume. Tumors tend to regress under adequate adrenal suppression with steroids. Surgery in not indicated to treat TART. DISCUSSION The reported prevalence of TART depends on age, usage of systematic follow-up ultrasound, and adequate CAH control. Timely detection of the disease is important to avoid irreversible gonadal dysfunction (not clinically apparent, due to high serum levels of androgen) and infertility. The relationship between TART and specific CAH phenotypes/genotypes has not been proved, and some cases do not present abnormal serum ACTH levels. Knowledge about TART should be disseminated among non-experts, to avoid unnecessary orchiectomies and false diagnosis of malignant testis tumors. Infertility is frequent, but has not been not satisfactorily addressed by physicians, even among experts. Sperm cryopreservation should be early offered to CAH adult males, but there are offer problems related to high cost.
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Affiliation(s)
- Lisieux Eyer de Jesus
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil.
| | - Ana Paula Paz de Oliveira
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil
| | - Luiza Coutinho Porto
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil
| | - Samuel Dekermacher
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil
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Weniger M, Mattes M, Grünewald TGP, Köhler K, Hübner A, Beuschlein F, Reisch N. Quantitative Characterization of Ectopic Adrenal Gene Expression in Fetal Testes in 21-Hydroxylase Deficient Mice. Horm Metab Res 2024; 56:38-44. [PMID: 38171371 DOI: 10.1055/a-2216-0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Testicular adrenal rest tumors (TART) are a frequent and fertility impairing long-term complication in males with classic congenital adrenal hyperplasia. Due to lack of clear experimental data on their origin, they are hypothesized to be derived from ectopic adrenocortical cells within testicular tissue mainly growing upon stimulation by chronically elevated levels of adrenocorticotropin (ACTH). Alternatively, a more totipotent embryological origin has been discussed as the potential source of these tumors. The aim of this study was to quantify alterations of ectopic expression of adrenocortical genes (CYP11B1, CYP11B2, CYP21, MC2R) and the Leydig cell specific marker (INSL3) in testicular tissue of fetal 21-hydroxylase deficient (21OHD) mice. Timed-pregnancy studies were performed using H-2aw18 (aw18)-mice. Testes and adrenals of E15.5 and E18.5 mouse fetuses were used for real-time PCR and immunohistochemistry. Gene expression levels were analyzed for genotype-dependent alterations and compared with immunohistochemistry. While enzymes of steroidogenesis showed a significant increased expression in adrenals of 21OHD mice at both E15.5 and E18.5 compared to wild-type (WT) mice, expression levels were unaltered in testes of 21OHD mice. When compared to WT adrenals a significant increase of INSL3 expression in adrenals of 21OHD mice at E15.5 and E18.5 was detected. Cells with adrenocortical properties in mice fetal testis differ from in situ adrenocortical cells in gene expression and growth at E15.5 and E18.5. These findings suggest that the different local regulation and different local niche in adrenals and testes influence growth of aberrant adrenal cells.
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Affiliation(s)
| | - Maria Mattes
- Medizinische Klinik IV, LMU Klinikum München, Munich, Germany
| | - Thomas G P Grünewald
- Max Eder Research Group for Pediatric Sarcoma Biology, Institute of Pathology, LMU Klinikum München, Munich, Germany
| | - Katrin Köhler
- Pediatric Endocrinology, Children's Hospital, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Angela Hübner
- Pediatric Endocrinology, Children's Hospital, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Felix Beuschlein
- Medizinische Klinik IV, LMU Klinikum München, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Nicole Reisch
- Medizinische Klinik IV, LMU Klinikum München, Munich, Germany
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Balagamage C, Arshad A, Elhassan YS, Ben Said W, Krone RE, Gleeson H, Idkowiak J. Management aspects of congenital adrenal hyperplasia during adolescence and transition to adult care. Clin Endocrinol (Oxf) 2023. [PMID: 37964596 DOI: 10.1111/cen.14992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/11/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023]
Abstract
The adolescent period is characterised by fundamental hormonal changes, which affect sex steroid production, cortisol metabolism and insulin sensitivity. These physiological changes have a significant impact on patients with congenital adrenal hyperplasia (CAH). An essential treatment aim across the lifespan in patients with CAH is to replace glucocorticoids sufficiently to avoid excess adrenal androgen production but equally to avoid cardiometabolic risks associated with excess glucocorticoid intake. The changes to the hormonal milieu at puberty, combined with poor adherence to medical therapy, often result in unsatisfactory control exacerbating androgen excess and increasing the risk of metabolic complications due to steroid over-replacement. With the physical and cognitive maturation of the adolescent with CAH, fertility issues and sexual function become a new focus of patient care in the paediatric clinic. This requires close surveillance for gonadal dysfunction, such as irregular periods/hirsutism or genital surgery-associated symptoms in girls and central hypogonadism or testicular adrenal rest tumours in boys. To ensure good health outcomes across the lifespan, the transition process from paediatric to adult care of patients with CAH must be planned carefully and early from the beginning of adolescence, spanning over many years into young adulthood. Its key aims are to empower the young person through education with full disclosure of their medical history, to ensure appropriate follow-up with experienced physicians and facilitate access to multispecialist teams addressing the complex needs of patients with CAH.
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Affiliation(s)
- Chamila Balagamage
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Amynta Arshad
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- The Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yasir S Elhassan
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Wogud Ben Said
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ruth E Krone
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Helena Gleeson
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jan Idkowiak
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Ahn CH, Shim J, Jang HN, Lee YA, Lee SW, Choi MH, Kim JH. Serum steroid profile captures metabolic phenotypes in adults with classic congenital adrenal hyperplasia. J Steroid Biochem Mol Biol 2023; 234:106374. [PMID: 37572762 DOI: 10.1016/j.jsbmb.2023.106374] [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: 06/19/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES Adult patients with classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency have an increased risk of metabolic diseases. We aimed to investigate whether liquid chromatography-mass spectrometry (LC-MS)-based serum steroid profiling reveals metabolic phenotypes in adults with classic CAH. DESIGN AND METHODS This study prospectively enrolled 63 adult patients with CAH and 38 healthy volunteers. The levels of the 24 steroids were quantified in the morning serum using LC-MS. Unsupervised clustering algorithms were applied to the serum steroid profiles to identify unique patterns associated with metabolic syndrome. RESULTS Serum steroid profiles of patients with CAH were clearly delineated from those of healthy controls with a higher degree of interindividual heterogeneity. The unsupervised clustering algorithm divided CAH patients into two clusters based on serum steroid profile. Cluster 2 showed higher serum levels of glucocorticoids and androgens than cluster 1. The prevalence of metabolic syndrome was significantly higher in cluster 2 than in cluster 1 (37.8 % vs. 5.6 %, P = 0.011). Other clinical characteristics, including age, sex, body mass index, CAH subtypes, and glucocorticoid dose, did not differ between the two clusters. The multivariate logistic regression model of selective 15 steroids could discriminate metabolic syndrome in patients with CAH with an area under the receiver operating characteristic curve of 0.832 (95 % confidence interval:0.732-0.933). CONCLUSIONS Serum steroid profiles can be valuable biomarkers for estimating metabolic risk in adult patients with CAH.
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Affiliation(s)
- Chang Ho Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Jaeyoon Shim
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Republic of Korea; Department of Chemistry, Korea University, Republic of Korea
| | - Han Na Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Republic of Korea; Department of Pediatrics, Seoul National University Hospital, Republic of Korea
| | - Sang-Won Lee
- Department of Chemistry, Korea University, Republic of Korea
| | - Man Ho Choi
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Republic of Korea.
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Hospital, Republic of Korea.
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Ortolano R, Cassio A, Alqaisi RS, Candela E, Di Natale V, Assirelli V, Bernardini L, Bortolamedi E, Cantarelli E, Corcioni B, Renzulli M, Balsamo A, Baronio F. Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia: Study of a Cohort of Patients from a Single Italian Center. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1457. [PMID: 37761418 PMCID: PMC10528159 DOI: 10.3390/children10091457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023]
Abstract
Testicular adrenal rest tumors (TARTs) are a common complication in male patients with congenital adrenal hyperplasia (CAH). The aim of our cross-sectional cohort study is to estimate the frequency of TARTs with the correlation of genotype and disease control on tumor development. Thirty-five male patients, aged 14-26 years, were included in the study, all followed by the same center of pediatric endocrinology in Bologna. We studied genotypes, hormonal profiles at different time intervals and testicular ultrasound. A logistic regression model with multivariant analysis was developed for the statistical analysis. TARTs were detected in 31.4% of the cases, 90.9% of them had a classic form with salt wasting, while 9.1% had a non-classic form. Additionally, a significant correlation between the incidence of TARTs and severity of genotype was detected. Patients with TARTs had markedly worse metabolic control on average (p = 0.027), reflected by high ACTH, 17OH progesterone, and overall delta4-androstenedione. In conclusion, a screening tool is mandatory, especially (but not exclusively) in patients with the most severe forms of CAH and poor endocrine control of the disease.
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Affiliation(s)
- Rita Ortolano
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.O.); (A.C.); (R.S.A.); (V.D.N.); (V.A.); (F.B.)
| | - Alessandra Cassio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.O.); (A.C.); (R.S.A.); (V.D.N.); (V.A.); (F.B.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy;
| | - Randa S. Alqaisi
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.O.); (A.C.); (R.S.A.); (V.D.N.); (V.A.); (F.B.)
- Pediatric and Neonatology Department, Faculty of Medicine and Surgery, Mu’tah University, Alkarak 61710, Jordan
| | - Egidio Candela
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.O.); (A.C.); (R.S.A.); (V.D.N.); (V.A.); (F.B.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy;
| | - Valeria Di Natale
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.O.); (A.C.); (R.S.A.); (V.D.N.); (V.A.); (F.B.)
| | - Valentina Assirelli
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.O.); (A.C.); (R.S.A.); (V.D.N.); (V.A.); (F.B.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy;
| | - Luca Bernardini
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy; (L.B.); (E.B.); (E.C.)
| | - Elisa Bortolamedi
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy; (L.B.); (E.B.); (E.C.)
| | - Erika Cantarelli
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy; (L.B.); (E.B.); (E.C.)
| | - Beniamino Corcioni
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (B.C.); (M.R.)
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (B.C.); (M.R.)
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy;
| | - Federico Baronio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.O.); (A.C.); (R.S.A.); (V.D.N.); (V.A.); (F.B.)
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Sarafoglou K, Merke DP, Reisch N, Claahsen-van der Grinten H, Falhammar H, Auchus RJ. Interpretation of Steroid Biomarkers in 21-Hydroxylase Deficiency and Their Use in Disease Management. J Clin Endocrinol Metab 2023; 108:2154-2175. [PMID: 36950738 PMCID: PMC10438890 DOI: 10.1210/clinem/dgad134] [Citation(s) in RCA: 2] [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] [Received: 02/06/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
The most common form of congenital adrenal hyperplasia is 21-hydroxylase deficiency (21OHD), which in the classic (severe) form occurs in roughly 1:16 000 newborns worldwide. Lifelong treatment consists of replacing cortisol and aldosterone deficiencies, and supraphysiological dosing schedules are typically employed to simultaneously attenuate production of adrenal-derived androgens. Glucocorticoid titration in 21OHD is challenging as it must balance the consequences of androgen excess vs those from chronic high glucocorticoid exposure, which are further complicated by interindividual variability in cortisol kinetics and glucocorticoid sensitivity. Clinical assessment and biochemical parameters are both used to guide therapy, but the specific purpose and goals of each biomarker vary with age and clinical context. Here we review the approach to medication titration for children and adults with classic 21OHD, with an emphasis on how to interpret adrenal biomarker values in guiding this process. In parallel, we illustrate how an understanding of the pathophysiologic and pharmacologic principles can be used to avoid and to correct complications of this disease and consequences of its management using existing treatment options.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, Division of Pediatric Endocrinology, 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
| | - Deborah P Merke
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Hedi Claahsen-van der Grinten
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - Richard J Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Ferreux L, Boumerdassi Y, Dulioust E, Bertagna X, Roucher-Boulez F, Bourdon M, Thiounn N, Patrat C. Testicular impairment in Primary Adrenal Insufficiency caused by Nicotinamide Nucleotide Transhydrogenase (NNT) deficiency - a case report: implication of oxidative stress and importance of fertility preservation. Basic Clin Androl 2023; 33:17. [PMID: 36918776 PMCID: PMC10015661 DOI: 10.1186/s12610-022-00176-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/08/2022] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION Nicotinamide nucleotide transhydrogenase (NNT) gene deficiency has recently been shown to be involved in Primary Adrenal Insufficiency (PAI). NNT encodes an inner mitochondrial membrane protein that produces large amounts of NADPH. NADPH is used in several biosynthesis pathways and the oxidoreduction of free radicals by the glutathione and thioredoxin systems in mitochondria. Patients with PAI due to NNT deficiency may also exhibit extra-adrenal manifestations, usually including gonadal impairment. CASE REPORT We present the case of a 35-year-old patient referred to our center for primary infertility with non-obstructive azoospermia, in a context of PAI and obesity. PAI genetic exploration carried out at the age of thirty revealed NNT deficiency due to the presence of two deleterious mutations (one on each allele) in the NNT gene. Scrotal ultrasound revealed a right Testicular Adrenal Rest Tumor (TART). Intensification of glucocorticoid therapy over the course of 8 months failed to reduce the TART volume or improve sperm production and endocrine function. No spermatozoa were found after surgical exploration of both testes, and subsequent histopathological analysis revealed bilateral Sertoli cell-only syndrome. A retrospective review of the hypothalamic-pituitary-gonadic axis hormonal assessment over 20 years showed progressive impairment of testicular function, accelerated during adulthood, leading to hypergonadotropic hypogonadism and non-obstructive azoospermia when the patient reached his thirties, while the PAI remained controlled over the same period. CONCLUSION This case report provides, for the first time, direct evidence of complete germ line loss in an azoospermic man with NNT deficiency. Additional data further support the hypothesis of a determinant role of oxidative cellular damage due to reactive oxygen species (ROS) imbalance in the severe gonadal impairment observed in this NNT-deficient patient. Early and regular evaluation of gonadal function should be performed in patients with PAI, especially with NNT deficiency, as soon as the patients reach puberty. Fertility preservation options should then be provided in early adulthood for these patients.
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Affiliation(s)
- Lucile Ferreux
- Service de Biologie de La Reproduction-CECOS, CHU Cochin - Bâtiment Port Royal, Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris CitéHôpital Cochin, 123 Boulevard de Port-Royal, 75679, Paris 14, France.
| | - Yasmine Boumerdassi
- Service de Biologie de La Reproduction-CECOS, CHU Cochin - Bâtiment Port Royal, Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris CitéHôpital Cochin, 123 Boulevard de Port-Royal, 75679, Paris 14, France
| | - Emmanuel Dulioust
- Service de Biologie de La Reproduction-CECOS, CHU Cochin - Bâtiment Port Royal, Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris CitéHôpital Cochin, 123 Boulevard de Port-Royal, 75679, Paris 14, France.,Université de Paris Cité Institut Cochin, U1016, INSERM, CNRS, F-75014, Paris, France
| | - Xavier Bertagna
- Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris Cité, Hôpital Cochin, Service d'endocrinologie Et Maladies Métaboliques, Paris, France
| | - Florence Roucher-Boulez
- Hospices Civils de Lyon, HCL. Centre - Laboratoire de Biochimie Et Biologie Moléculaire, UM Endocrinologie- Centre de Référence du Développement Génital- Univ Lyon, Université Claude Bernard, Lyon 1, Lyon, France
| | - Mathilde Bourdon
- Université de Paris Cité Institut Cochin, U1016, INSERM, CNRS, F-75014, Paris, France.,Hôpitaux de Paris (AP-HP), AP-HP. Centre - Université de Paris Cité, Hôpital Cochin, Service de Gynécologie-Obstétrique II Et de Médecine de La Reproduction, Paris, France
| | - Nicolas Thiounn
- Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris Cité, Hôpital Européen Georges-Pompidou (HEGP), Service d'Urologie, Paris, France
| | - Catherine Patrat
- Service de Biologie de La Reproduction-CECOS, CHU Cochin - Bâtiment Port Royal, Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris CitéHôpital Cochin, 123 Boulevard de Port-Royal, 75679, Paris 14, France.,Université de Paris Cité Institut Cochin, U1016, INSERM, CNRS, F-75014, Paris, France
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Righi B, Ali SR, Bryce J, Tomlinson JW, Bonfig W, Baronio F, Costa EC, Guaragna-Filho G, T'Sjoen G, Cools M, Markosyan R, Bachega TASS, Miranda MC, Iotova V, Falhammar H, Ceccato F, Stancampiano MR, Russo G, Daniel E, Auchus RJ, Ross RJ, Ahmed SF. Long-term cardiometabolic morbidity in young adults with classic 21-hydroxylase deficiency congenital adrenal hyperplasia. Endocrine 2023; 80:630-638. [PMID: 36857009 PMCID: PMC10199864 DOI: 10.1007/s12020-023-03330-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/12/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE To study the current practice for assessing comorbidity in adults with 21-hydroxylase CAH and to assess the prevalence of comorbidity in these adults. METHODS A structured questionnaire was sent to 46 expert centres managing adults with CAH. Information collected included current therapy and surveillance practice with a particular focus on osteoporosis/osteopaenia, hyperlipidaemia, type 2 diabetes/hyperinsulinaemia, hypertension, CV disease, obesity. RESULTS Of the 31 (67%) centres from 15 countries that completed the survey, 30 (97%) screened for hypertension by measuring blood pressure, 30 (97%) screened for obesity, 26 (84%) screened for abnormal glucose homoeostasis mainly by using Hb1Ac (73%), 25 (81%) screened for osteoporosis mainly by DXA (92%), 20 (65%) screened for hyperlipidaemia and 6 (19%) screened for additional CV disease. Of the 31 centres, 13 provided further information on the six co-morbidities in 244 patients with a median age of 33 yrs (range 19, 94). Of these, 126 (52%) were females and 174 (71%) received fludrocortisone in addition to glucocorticoids. Of the 244 adults, 73 (30%) were treated for at least one comorbidity and 15 (21%) for more than 2 co-morbidities. Of 73, the patients who were treated for osteoporosis/osteopaenia, hyperlipidaemia, type 2 diabetes/hyperinsulinaemia, hypertension, CV disease, obesity were 43 (59%), 17 (23%), 16 (22%), 10 (14%), 8 (11), 3 (4%) respectively. CONCLUSION Cardiometabolic and bone morbidities are not uncommon in adults with CAH. There is a need to standardise the screening for these morbidities from early adulthood and to explore optimal therapy through routine collection of standardised data.
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Affiliation(s)
- Beatrice Righi
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital For Sick Children, Glasgow, UK.
- Department of Mother and Child, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Salma R Ali
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital For Sick Children, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Jillian Bryce
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology & Metabolism, NIHR Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, UK
| | - Walter Bonfig
- Department of Paediatrics, Technical University München, Munich, Germany
- Department of Paediatrics, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Federico Baronio
- Pediatric Unit, Department Hospital of Woman And Child, IRCSS S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Eduardo C Costa
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Guilherme Guaragna-Filho
- Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Guy T'Sjoen
- Department of Endocrinology - Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Martine Cools
- Department of Internal Medicine and Paediatrics, Ghent University and Department of Pediatric Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Renata Markosyan
- Endocrinology, Yerevan State Medical University Endocrinology Clinic, Yerevan, Armenia
| | - Tania A S S Bachega
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Mirela C Miranda
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Violeta Iotova
- UMHAT Sveta Marina, Medical University of Varna, Varna, Bulgaria
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua, Italy
| | - Marianna R Stancampiano
- Department of Pediatrics, Endocrine Unit, IRCCS San Raffaele Scientific Institute, Endo-ERN Center for Rare Endocrine Conditions, Milan, Italy
| | - Gianni Russo
- Department of Pediatrics, Endocrine Unit, IRCCS San Raffaele Scientific Institute, Endo-ERN Center for Rare Endocrine Conditions, Milan, Italy
| | - Eleni Daniel
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Richard J Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital For Sick Children, Glasgow, UK
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Gusmano C, Cannarella R, Crafa A, Barbagallo F, La Vignera S, Condorelli RA, Calogero AE. Congenital adrenal hyperplasia, disorders of sex development, and infertility in patients with POR gene pathogenic variants: a systematic review of the literature. J Endocrinol Invest 2023; 46:1-14. [PMID: 35842891 PMCID: PMC9829634 DOI: 10.1007/s40618-022-01849-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/23/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND P450 oxidoreductase (POR) deficiency (PORD) is characterized by congenital adrenal hyperplasia (CAH) and disorders of sex development (DSD) in both sexes. PORD can also associate with skeletal defects. However, the prevalence of these phenotypes is unknown. AIM To evaluate the prevalence of CAH, DSD, and infertility of patients with POR gene pathogenic variants by a systematic review of the literature. METHODS The literature search was performed through PubMed, MEDLINE, Cochrane, Academic One Files, Google Scholar, and Scopus databases. All studies reporting information on CAH, DSD, testicular adrenal rest tumor (TARTs), and fertility in patients with POR gene pathogenic variants were included. Finally, the prevalence of abnormal phenotypes was calculated. RESULTS Of the 246 articles initially retrieved, only 48 were included for a total of 119 (46 males and 73 females) patients with PORD. We also included the case of a male patient who consulted us for CAH and TARTs but without DSD. This patient, found to be a carrier of combined heterozygous POR mutation, reached fatherhood spontaneously. All the patients found had CAH. The presence of DSD was found in 65.2%, 82.1%, and 82.1% of patients with compound heterozygosity, homozygosity, or monoallelic heterozygous variants, respectively. The prevalence was significantly higher in females than in males. The prevalence of TARTs in patients with PORD is 2.7%. Only 5 women with PORD became pregnant after assisted reproductive techniques and delivered a healthy baby. Except for the recently reported proband, no other studies focused on male infertility in patients with POR gene variants. CONCLUSION This systematic review of the literature reports the prevalence of CAH, DSD, and TARTs in patients with PORD. The unknown prevalence of POR gene pathogenetic variants and the paucity of studies investigating fertility do not allow us to establish whether PORD is associated with infertility. Further studies on both women and men are needed to clarify this relationship.
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Affiliation(s)
- C Gusmano
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - R Cannarella
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - A Crafa
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - F Barbagallo
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - S La Vignera
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - R A Condorelli
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - A E Calogero
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy.
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Chougar T, Laanani M, Ferreux L, Chalas C, Wolf JP, Bertherat J, Bouvattier C, Polak M, Bachelot A, Dulon J, Touraine P, Patrat C, Drouineaud V. Sperm cryopreservation in young males with congenital adrenal hyperplasia (CAH). Clin Endocrinol (Oxf) 2022; 97:860-862. [PMID: 35746828 DOI: 10.1111/cen.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/23/2022] [Accepted: 06/13/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Taous Chougar
- Assistance publique, Hôpitaux de Paris (AP-HP) Centre, Université de Paris, Cochin, Service de Biologie de la Reproduction, CECOS, Paris, France
| | - Moussa Laanani
- Assistance Publique-Hôpitaux de Paris (AP-HP), Centre-Université de Paris, Hôpital Hôtel Dieu, Service de Biostatistique et d'Epidémiologie, Paris, France
| | - Lucile Ferreux
- Assistance publique, Hôpitaux de Paris (AP-HP) Centre, Université de Paris, Cochin, Service de Biologie de la Reproduction, CECOS, Paris, France
| | - Céline Chalas
- Assistance publique, Hôpitaux de Paris (AP-HP) Centre, Université de Paris, Cochin, Service de Biologie de la Reproduction, CECOS, Paris, France
| | - Jean-Philippe Wolf
- Assistance publique, Hôpitaux de Paris (AP-HP) Centre, Université de Paris, Cochin, Service de Biologie de la Reproduction, CECOS, Paris, France
- Université Paris Cité, UMR 1016, Institut Cochin, From Gametes to Birth, Paris, France
| | - Jérôme Bertherat
- Assistance Publique-Hôpitaux de Paris (AP-HP), Centre-Université de Paris, Hôpital Cochin, Service d'Endocrinologie, Centre de Référence Maladies Rares de la Surrénale, Paris, France
- Service d'Endocrinologie, Sorbonne Université médecine, Paris, France
| | - Claire Bouvattier
- AP-HP, Université Paris-Saclay, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, France
| | - Michel Polak
- Service d'Endocrinologie, Sorbonne Université médecine, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Centre-Université de Paris, Hôpital Necker, Service d'endocrinologie, diabétologie, gynécologie pédiatriques, Paris, France
| | - Anne Bachelot
- Service d'Endocrinologie, Sorbonne Université médecine, Paris, France
- AP-HP, Sorbonne Université, Hôpital Universitaire Pitié Salpêtrière-Charles Foix, Service d'Endocrinologie et Médecine de la Reproduction, Centre de Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Pathologies Gynécologiques Rares, Paris, France
| | - Jérôme Dulon
- AP-HP, Sorbonne Université, Hôpital Universitaire Pitié Salpêtrière-Charles Foix, Service d'Endocrinologie et Médecine de la Reproduction, Centre de Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Pathologies Gynécologiques Rares, Paris, France
| | - Philippe Touraine
- Service d'Endocrinologie, Sorbonne Université médecine, Paris, France
- AP-HP, Sorbonne Université, Hôpital Universitaire Pitié Salpêtrière-Charles Foix, Service d'Endocrinologie et Médecine de la Reproduction, Centre de Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Pathologies Gynécologiques Rares, Paris, France
| | - Catherine Patrat
- Assistance publique, Hôpitaux de Paris (AP-HP) Centre, Université de Paris, Cochin, Service de Biologie de la Reproduction, CECOS, Paris, France
- Université Paris Cité, UMR 1016, Institut Cochin, From Gametes to Birth, Paris, France
- FHU PREMA, Paris, France
| | - Véronique Drouineaud
- Assistance publique, Hôpitaux de Paris (AP-HP) Centre, Université de Paris, Cochin, Service de Biologie de la Reproduction, CECOS, Paris, France
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12
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Guo X, Zhang Y, Yu Y, Zhang L, Ullah K, Ji M, Jin B, Shu J. Getting pregnant with congenital adrenal hyperplasia: Assisted reproduction and pregnancy complications. A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2022; 13:982953. [PMID: 36120452 PMCID: PMC9470834 DOI: 10.3389/fendo.2022.982953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Many patients with congenital adrenal hyperplasia (CAH) refrain from seeking pregnancy, suffer from infertility or worry about pregnancy complications, mainly due to genitalia abnormalities, anovulation, unreceptive endometrium and metabolic disturbances. Despite those challenges, many live births have been reported. In this systematic review, we focused on the key to successful assisted reproduction strategies and the potential pregnancy complications. We did a systematic literature search of Pubmed, Medline and Scopus for articles reporting successful pregnancies in CAH other than 21-hydroxylase deficiency, and found 25 studies reporting 39 pregnancies covering deficiency in steroidogenic acute regulatory protein, 17α-hydroxylase/17,20-lyase, 11β-hydroxylase, P450 oxidoreductase, cytochrome b5 and 3β-hydroxysteroid dehydrogenase. We summarized various clinical manifestations and tailored reproduction strategy for each subtype. Furthermore, a meta-analysis was performed to evaluate the pregnancy complications of CAH patients. A total of 19 cross-sectional or cohort studies involving 1311 pregnancies of classic and non-classic CAH patients were included. Surprisingly, as high as 5.5% (95% CI 2.3%-9.7%) of pregnancies were electively aborted, and the risk was significantly higher in those studies with a larger proportion of classic CAH than those with only non-classical patients (8.43% (4.1%-13.81%) VS 3.75%(1.2%-7.49%)), which called for better family planning. Pooled incidence of miscarriage was 18.2% (13.4%-23.4%) with a relative risk (RR) of 1.86 (1.27-2.72) compared to control. Glucocorticoid treatment in non-classical CAH patients significantly lowered the miscarriage rate when compared to the untreated group (RR 0.25 (0.13-0.47)). CAH patients were also more susceptible to gestational diabetes mellitus, with a prevalence of 7.3% (2.4%-14.1%) and a RR 2.57 (1.29-5.12). However, risks of preeclampsia, preterm birth and small for gestational age were not significantly different. 67.8% (50.8%-86.9%) CAH patients underwent Cesarean delivery, 3.86 (1.66-8.97) times the risk of the control group. These results showed that fertility is possible for CAH patients but special care was necessary when planning, seeking and during pregnancy. Systematic Review Registration PROSPERO https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=342642, CRD42022342642.
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Affiliation(s)
- Xiaoyan Guo
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yu Zhang
- School of Nursing, Hangzhou Medical College, Hangzhou, China
| | - Yiqi Yu
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Ling Zhang
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Kamran Ullah
- Department of Biology, The University of Haripur, Haripur, Pakistan
| | - Mengxia Ji
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Bihui Jin
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Jing Shu
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
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13
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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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14
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Abstract
Treatment for congenital adrenal hyperplasia (CAH) was introduced in the 1950s following the discovery of the structure and function of adrenocortical hormones. Although major advances in molecular biology have delineated steroidogenic mechanisms and the genetics of CAH, management and treatment of this condition continue to present challenges. Management is complicated by a combination of comorbidities that arise from disease-related hormonal derangements and treatment-related adverse effects. The clinical outcomes of CAH can include life-threatening adrenal crises, altered growth and early puberty, and adverse effects on metabolic, cardiovascular, bone and reproductive health. Standard-of-care glucocorticoid formulations fall short of replicating the circadian rhythm of cortisol and controlling efficient adrenocorticotrophic hormone-driven adrenal androgen production. Adrenal-derived 11-oxygenated androgens have emerged as potential new biomarkers for CAH, as traditional biomarkers are subject to variability and are not adrenal-specific, contributing to management challenges. Multiple alternative treatment approaches are being developed with the aim of tailoring therapy for improved patient outcomes. This Review focuses on challenges and advances in the management and treatment of CAH due to 21-hydroxylase deficiency, the most common type of CAH. Furthermore, we examine new therapeutic developments, including treatments designed to replace cortisol in a physiological manner and adjunct agents intended to control excess androgens and thereby enable reductions in glucocorticoid doses.
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Affiliation(s)
- Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD, USA.
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
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15
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Carrière C, Sarfati C, Téjédor I, Dulon J, Chakhtoura Z, Courtillot C, Bachelot A. Classical and non-classical congenital adrenal hyperplasia: what is the difference in subsequent fertility? ANNALES D'ENDOCRINOLOGIE 2022; 83:181-185. [PMID: 35489415 DOI: 10.1016/j.ando.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
21-Hydroxylase deficiency (21OHD) is the most common cause of congenital adrenal hyperplasia. Increased production of adrenal-derived androgens and progesterone in 21OHD women interfere with their reproductive function and their fertility in many different ways, depending on the severity of the disease. Sexuality and fertility in women with classic 21OHD is impaired, due to several issues such as disrupted gonadotropic axis due to androgen and progesterone overproduction, and mechanical, psychological factors related to genital surgery. Fertility and fecundity in these women get better over the years. Subfertility seems contrariwise to be relative in non-classic 21OHD women. Before pregnancy, genotyping the partner and genetic counselling is mandatory.
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Affiliation(s)
- Camille Carrière
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
| | - Cynthia Sarfati
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France; UPMC Université Pierre et Marie Curie, Univ Paris 06, Paris, France
| | - Isabelle Téjédor
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
| | - Jérôme Dulon
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
| | - Zeina Chakhtoura
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
| | - Carine Courtillot
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France
| | - Anne Bachelot
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN, Paris, France; UPMC Université Pierre et Marie Curie, Univ Paris 06, Paris, France.
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Ilboudo A, Yempabou S, Sophie D, Philippe T, Courtillot C. Infertility with hypogonadotropic hypogonadism revealing a classic form of 21 hydroxylase deficiency in a 39 year-old man. ANNALES D'ENDOCRINOLOGIE 2022; 83:267-268. [DOI: 10.1016/j.ando.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022]
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17
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Kim JH, Choi S, Lee YA, Lee J, Kim SG. Epidemiology and Long-Term Adverse Outcomes in Korean Patients with Congenital Adrenal Hyperplasia: A Nationwide Study. Endocrinol Metab (Seoul) 2022; 37:138-147. [PMID: 35255606 PMCID: PMC8901972 DOI: 10.3803/enm.2021.1328] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/20/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Previous studies on the epidemiology and complications of congenital adrenal hyperplasia (CAH) were conducted in Western countries and in children/adolescents. We aimed to explore the epidemiology of CAH, as well as the risk of comorbidities and mortality, in a Korean nationwide case-control study. METHODS CAH patients (n=2,840) were included between 2002 and 2017 from the National Health Insurance Service database and the Rare Intractable Disease program. CAH patients were compared, at a 1:10 ratio, with age-, sex-, and index year-matched controls (n=28,400). RESULTS The point prevalence of CAH patients in Korea was 1 in 18,745 persons in 2017. The annual incidence rate declined between 2003 and 2017 from 3.25 to 0.41 per 100,000 persons. CAH patients were at elevated risk for cardiovascular disease (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.4 to 1.9), stroke (OR, 1.7; 95% CI, 1.3 to 2.0), diabetes mellitus (OR, 2.8; 95% CI, 2.6 to 3.1), dyslipidemia (OR, 2.4; 95% CI, 2.2 to 2.6), and psychiatric disorders (OR, 1.5; 95% CI, 1.3 to 1.6). Fracture risk increased in CAH patients aged over 40 years (OR, 1.4; 95% CI, 1.1 to 1.7). CAH patients were at higher risk of mortality than controls (hazard ratio, 1.6; 95% CI, 1.3 to 2.0). CONCLUSION Our nationwide study showed a recent decline in the incidence of CAH and an elevated risk for cardiovascular, metabolic, skeletal, and psychiatric disorders in CAH patients. Lifelong management for comorbidity risk is a crucial component of treating CAH patients.
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Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul,
Korea
| | - Sunkyu Choi
- Department of Biostatistics, Korea University College of Medicine, Seoul,
Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul,
Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul,
Korea
| | - Sin Gon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul,
Korea
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 156] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Barbot M, Mazzeo P, Lazzara M, Ceccato F, Scaroni C. Metabolic syndrome and cardiovascular morbidity in patients with congenital adrenal hyperplasia. Front Endocrinol (Lausanne) 2022; 13:934675. [PMID: 35979433 PMCID: PMC9376294 DOI: 10.3389/fendo.2022.934675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
Since the introduction of glucocorticoid (GC) replacement therapy, congenital adrenal hyperplasia (CAH) is no longer a fatal disease. The development of neonatal screening programs and the amelioration of GC treatment strategies have improved significantly life expectancy in CAH patients. Thanks to these achievements, CAH patients are now in their adulthood, but an increased incidence of cardiovascular risk factors has been reported compared to general population in this stage of life. The aim of CAH treatment is to both prevent adrenal insufficiency and suppress androgen excess; in this delicate balance, under- as well as overtreatment might be equally harmful to long-term cardiovascular health. This work examines the prevalence of metabolic features and cardiovascular events, their correlation with hormone levels and GC replacement regimen in CAH patients and focuses on precocious markers to early detect patients at higher risk and new potential treatment approaches.
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Abstract
PURPOSE OF REVIEW The introduction of synthetic glucocorticoids 70 years ago made survival possible in classic 21-hydroxylase deficiency (21OHD). The currently used glucocorticoid therapy may lead to unphysiological dosing with negative consequencies on health in addition to the problems that may arise due to androgen over-exposure. RECENT FINDINGS Fertility in females with 21OHD seemed to be impaired, especially in the salt-wasting (SW) phenotype but when pregnancies did occur there was a higher risk for gestational diabetes and cesearean section. Increased fat mass, body mass index, insulin resistance and frequency of autoimmune disorders as well as impaired echocardiographic parameters and lower bone mineral density were found in 21OHD compared to controls. Negative effects on cognitive functions have been identified. Adrenal tumors, especially myelolipomas, were prevalent. Increased knowledge on steroid metabolism in 21OHD and urine steroid profiling may improve assessment of treatment efficacy. Nevanimibe, abiraterone acetate and anastrozole may have a place in the future management of 21OHD. Long-acting glucocorticoids may be a less favorable, especially dexamethasone. SUMMARY The various clinical outcomes need regular monitoring. Negative consequencies are to large extent the result of the unphysiological glucocorticoid replacement. Modern management with improved follow-up and future addition of new drugs may improve outcomes.
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Affiliation(s)
- Anna Nordenström
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital
- Department of Women's and Children's Health, Karolinska Institutet
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital
- Department of Women's and Children's Health, Karolinska Institutet
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital
- Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Merke DP, Mallappa A, Arlt W, Brac de la Perriere A, Lindén Hirschberg A, Juul A, Newell-Price J, Perry CG, Prete A, Rees DA, Reisch N, Stikkelbroeck N, Touraine P, Maltby K, Treasure FP, Porter J, Ross RJ. Modified-Release Hydrocortisone in Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e2063-e2077. [PMID: 33527139 PMCID: PMC8063257 DOI: 10.1210/clinem/dgab051] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT Standard glucocorticoid therapy in congenital adrenal hyperplasia (CAH) regularly fails to control androgen excess, causing glucocorticoid overexposure and poor health outcomes. OBJECTIVE We investigated whether modified-release hydrocortisone (MR-HC), which mimics physiologic cortisol secretion, could improve disease control. METHODS A 6-month, randomized, phase 3 study was conducted of MR-HC vs standard glucocorticoid, followed by a single-arm MR-HC extension study. Primary outcomes were change in 24-hour SD score (SDS) of androgen precursor 17-hydroxyprogesterone (17OHP) for phase 3, and efficacy, safety and tolerability of MR-HC for the extension study. RESULTS The phase 3 study recruited 122 adult CAH patients. Although the study failed its primary outcome at 6 months, there was evidence of better biochemical control on MR-HC, with lower 17OHP SDS at 4 (P = .007) and 12 (P = .019) weeks, and between 07:00h to 15:00h (P = .044) at 6 months. The percentage of patients with controlled 09:00h serum 17OHP (< 1200 ng/dL) was 52% at baseline, at 6 months 91% for MR-HC and 71% for standard therapy (P = .002), and 80% for MR-HC at 18 months' extension. The median daily hydrocortisone dose was 25 mg at baseline, at 6 months 31 mg for standard therapy, and 30 mg for MR-HC, and after 18 months 20 mg MR-HC. Three adrenal crises occurred in phase 3, none on MR-HC and 4 in the extension study. MR-HC resulted in patient-reported benefit including menses restoration in 8 patients (1 on standard therapy), and 3 patient and 4 partner pregnancies (none on standard therapy). CONCLUSION MR-HC improved biochemical disease control in adults with reduction in steroid dose over time and patient-reported benefit.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Aude Brac de la Perriere
- Hospices Civils de Lyon, Fédération d’Endocrinologie, Groupement hospitalier Est, Bron Cedex, France
| | - Angelica Lindén Hirschberg
- Department of Women’s and Children’s Health, Karolinska Institutet and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D Aled Rees
- Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Pitie Salpêtriere Hospital, France
- Sorbonne University, Center for Rare Endocrine and Gynecological Disorders, Paris, France
| | | | | | | | - Richard J Ross
- University of Sheffield, Sheffield, UK
- Diurnal Ltd, Cardiff, UK
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San Martín P, Eugenio Russmann ML, Mendeluk G, Fierro MF, Marino R, Pardes E. Classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21-OHD) in adult males: Clinical presentation, hormone function and the detection of adrenal and testicular adrenal rest tumors (TARTs). ENDOCRINOL DIAB NUTR 2021; 68:227-235. [DOI: 10.1016/j.endinu.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
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San Martín P, Eugenio Russmann ML, Mendeluk G, Fierro MF, Marino R, Pardes E. Classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21-OHD) in adult males: Clinical presentation, hormone function and the detection of adrenal and testicular adrenal rest tumors (TARTs). ENDOCRINOL DIAB NUTR 2021; 68:227-235. [PMID: 34266634 DOI: 10.1016/j.endien.2020.07.003] [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: 02/29/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION 21-hydroxylase deficiency (21-OHD) is the most common form of congenital adrenal hyperplasia (CAH). In adulthood, most studies are reported in females. By contrast, data on adult males are scarce. OBJECTIVE To describe a series of adult males with classic 21-OHD and to assess the presence of adrenal masses and testicular adrenal rest tumors (TARTs). MATERIAL AND METHODS Eight males (21-42 years) were included. We evaluated clinical presentation, 17-Hydroxyprogesterone (17-OHP), Testosterone (T), Δ4Androstenedione (Δ4A) ACTH, LH, FSH and plasma renin activitiy (PRA) levels at consultation. Molecular studies of the CYP21A2 gene, testicular ultrasound (US), semen analysis and adrenal computed tomography (CT) scan were performed. Treatment and compliance were assessed. RESULTS Basal 17-OHP levels were >20ng/ml in all patients. At consultation, median 17OH-P was 11.5 (2.3-81) ng/ml, FSH: 3 (0.3-4) mUI/ml, LH: 1.1 (0.1-6) mUI/ml, T: 4.3 (1.7-8) ng/ml, Δ4A: 5.7 (1.4-16) ng/ml, ACTH: 86.4 (76-334) pg/ml, PRA: 9.5 (1.3-23.6) ng/ml/h. Semen analysis was performed in 5/8 patients, showing azoospermia in two. Molecular genetic analysis was performed in 4/8 patients. TARTs were found in 5/6, being bilateral in four. Adrenal masses were found in 4/6. In the 7 patients diagnosed in childhood, their follow-up was referred to as irregular, both in their attendance at consultations and in compliance with the indicated treatment. CONCLUSIONS To our knowledge, this is the first series on adult males with classic 21-OHD which concomitantly assesses clinical presentation, molecular biology, adrenal and testicular imaging studies, semen analysis and compliance to treatment. A high prevalence of adrenal masses and TARTs was observed, possibly associated with poor treatment compliance leading to elevated ACTH and increased proliferation. Our findings on TARTs agree with reports in international publications of CAH in males, with adrenal imaging being added in our group. Although we are aware that further studies with a larger sample size and more data are needed, we consider that our findings contribute to the clinical management of classical 21-OHD in the male population.
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Affiliation(s)
- Patricia San Martín
- Department of Endocrinology, Hospital JM Ramos Mejía, Urquiza 609, Zip Code 1221, Buenos Aires, Argentina.
| | | | - Gabriela Mendeluk
- Unit of Clinical Cytology, Hospital JM Ramos Mejía, Urquiza 609, Zip Code 1221, Buenos Aires, Argentina
| | - María Fabiana Fierro
- Department of Endocrinology, Hospital JM Ramos Mejía, Urquiza 609, Zip Code 1221, Buenos Aires, Argentina
| | - Roxana Marino
- Department of Endocrinology, Hospital de Pediatría JP Garrahan, Pichincha 1890, Zip Code 1245, Buenos Aires, Argentina
| | - Ester Pardes
- Department of Endocrinology, Hospital JM Ramos Mejía, Urquiza 609, Zip Code 1221, Buenos Aires, Argentina
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Corcioni B, Renzulli M, Marasco G, Baronio F, Gambineri A, Ricciardi D, Ortolano R, Farina D, Gaudiano C, Cassio A, Pagotto U, Golfieri R. Prevalence and ultrasound patterns of testicular adrenal rest tumors in adults with congenital adrenal hyperplasia. Transl Androl Urol 2021; 10:562-573. [PMID: 33718059 PMCID: PMC7947447 DOI: 10.21037/tau-20-998] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Testicular adrenal rest tumors (TARTs) are benign neoplasms affecting patients with congenital adrenal hyperplasia (CAH). The prevalence of TART in adult patients with CAH is not well known. Ultrasonography (US) is the main tool for diagnosing TART and the role of contrast-enhanced US (CEUS) is never investigated. The aim of this study was to evaluate the TART prevalence in adults with CAH, by stratifying patients according to disease phenotype and assessing the diagnostic performance of US, color Doppler (CD) US and CEUS. Methods Male patients >16 years old with certain diagnosis of CAH who underwent US for TARTs, between December 2015 and September 2019 were prospectively enrolled. The control group included patients without CAH affected by testicular lesions at US other than TARTs. Results TARTs were identified in 16 of 52 patients (31%), of whom 15 (93.8%) displayed the salt-wasting (SW) form (P<0.001). The prevalence of TARTs in patients with the SW form was 54%. One patient with the non-classic (NC) form (6%) showed TART (likely the first documented case). The mean age of patients upon detection of TARTs was significantly younger compared with the control group (P<0.001); moreover, TARTs were bilateral in 15/16 patients (93.8%; P<0.001) and the largest lesion was more frequent in the medium third of testis in the TART group (87.5%), statistically different from the control group (P=0.013). Conclusions TARTs almost exclusively affected patients with the SW form of CAH. Age at diagnosis and bilateralism are useful factors for achieving a correct diagnosis of TARTs in CAH adult patients.
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Affiliation(s)
- Beniamino Corcioni
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Federico Baronio
- Pediatric Unit, Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Alessandra Gambineri
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Domenico Ricciardi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Rita Ortolano
- Pediatric Unit, Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Farina
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Caterina Gaudiano
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandra Cassio
- Pediatric Unit, Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Hirschberg AL, Gidlöf S, Falhammar H, Frisén L, Almqvist C, Nordenskjöld A, Nordenström A. Reproductive and Perinatal Outcomes in Women with Congenital Adrenal Hyperplasia: A Population-based Cohort Study. J Clin Endocrinol Metab 2021; 106:e957-e965. [PMID: 33135723 DOI: 10.1210/clinem/dgaa801] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Reduced fertility has been reported for women with congenital adrenal hyperplasia (CAH), especially for those with the salt-losing form. However, data are sparse on reproductive and perinatal outcomes in these women. OBJECTIVE To investigate reproductive and perinatal outcomes in women with CAH. DESIGN AND SETTING Population-based and nationwide study using the National CAH Register, the Total Population Register, and the Medical Birth Register of Sweden. PARTICIPANTS A total of 272 women with CAH due to 21-hydroxylase deficiency and 27 200 controls matched by sex, age, and place of birth. The median age was 31 years. MAIN OUTCOME MEASURES The proportion of CAH women that have given birth, and reproductive and perinatal outcomes. RESULTS Of the 272 women with CAH, 69 gave birth to at least 1 child (25.4%), which was a lower frequency than for the controls (45.8%) (P < .001). Furthermore, women with CAH had fewer children than controls and were slightly older at birth of their first child. More women with CAH were diagnosed with gestational diabetes than controls, 4.9% versus 1.4% (P < .05), and more women with CAH were delivered through cesarean section, 51.4% versus 12.3% (P < .05). There was no difference in Apgar score or frequency of small-for-gestational age between children born to mothers with CAH and controls. CONCLUSIONS This is, to our knowledge, the largest cohort designed to investigate reproductive and perinatal outcomes in women with CAH. We found the birth rate to be lower in women with CAH; gestational diabetes and cesarean section were more common, but perinatal outcomes were comparable with controls.
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Affiliation(s)
- Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Sebastian Gidlöf
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Stockholm South General Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Child and Adolescent Psychiatry Research Centre, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Lung and Allergy Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Surgery, Astrid Lindgren's Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren's Children Hospital, Karolinska University Hospital, Stockholm, Sweden
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Lim SG, Lee YA, Jang HN, Kong SH, Ahn CH, Kim SW, Shin CH, Kim JH. Long-Term Health Outcomes of Korean Adults With Classic Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. Front Endocrinol (Lausanne) 2021; 12:761258. [PMID: 34712205 PMCID: PMC8547732 DOI: 10.3389/fendo.2021.761258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/27/2021] [Indexed: 01/14/2023] Open
Abstract
There is a lack of studies regarding the long-term outcomes of Asian adults with classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. We hypothesized that adults with CAH are at higher metabolic risk than their age-, and sex-matched controls. We further investigated the long-term health outcome-related factors in adults with CAH. We compared metabolic risk between adults with CAH (71 men, 93 women) and age-, and sex-matched controls (190 men, 261 women) from the Korean National Health and Nutrition Examination Survey data. The presence of obesity, testicular adrenal rest tumors (TARTs), and menstrual irregularity was assessed. Hormone status and treatment regimens were compared according to the presence of adverse outcomes. The median age was 27.0 y and 28.0 y for men and women, respectively. Adults with CAH had a higher waist circumference (88.0 vs. 82.3 cm in men, and 83.5 vs. 72.3 cm in women), and blood pressure (125.0 vs. 113.0 mmHg in men, and 120.0 vs. 104.0 mmHg in women) than age- and sex-matched controls (P<0.05 for all). The 2.7-fold increased risk for hypertension (men) and 2.0-fold increased risk for obesity (women) was significant in patients with CAH (P<0.05 for both). Obese adults with CAH showed significantly higher adrenal limb thicknesses (men) and 17-hydroxyprogesterone and dehydroepiandrosterone sulfate levels (women) (P<0.05 for both). TARTs occurred in 58.1% of men and did not differ by hormone or treatment regimen. Irregular menstruation was observed in 57.1% of women, with higher dehydroepiandrosterone sulfate levels in those with irregular periods. Adults with CAH had a higher metabolic risk than the general population. Poor disease control may increase their risk of metabolic morbidity and menstrual irregularity.
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Affiliation(s)
- Seung Gyun Lim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Jung Hee Kim, ; ; Young Ah Lee,
| | - Han Na Jang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sung Hye Kong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Jung Hee Kim, ; ; Young Ah Lee,
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Mittnacht J, Choukair D, Breil T, Klose D, Inta I, Bettendorf M. Relation of health-related quality of life to near final height and body composition in adolescents with chronic endocrinopathies during transition period. Clin Endocrinol (Oxf) 2020; 93:696-704. [PMID: 32682344 DOI: 10.1111/cen.14287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 07/02/2020] [Accepted: 07/12/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We evaluated sequelae of disease and therapy in adolescents with chronic endocrinopathies using a medical and psychological workup to record health-related quality of life (HRQoL), near final height (NFH) and body compositions during the transition period from paediatric to adult care. METHODS Near final height, weight, body mass index (BMI), grip strength (GS), hip and waist circumference (HC; WC), skin folds (SF) and HRQoL T-scores by KIDSCREEN and DISABKIDS were assessed in 134 patients (70 females and 64 males) from May 2010 to March 2016 diagnosed with congenital adrenal hyperplasia (CAH; n = 22), multiple pituitary hormone deficiency (MPHD; n = 17), growth hormone deficiency (GHD; n = 37), Turner syndrome (TS; n = 27), SGA-short stature (SGA; n = 20) and Klinefelter syndrome (KS; n = 11). RESULTS Median HRQoL T-scores for KIDSCREEN (50.6-56.5) and DISABKIDS (52.7-58.9) ranged within references with considerable variations but without significant deficit in any diagnosis. Median-corrected height SDS (CoH-SDS: NFH-SDS-TH [target height]-SDS) was >-1, except in KS (SDS + 1.3) and in TS (SDS - 1.9; P < .0001) without correlations with HRQoL. Median BMI was below 25 kg/m2 in all patients except MPHD (26.5 kg/m2 ; SDS 1.5; P = .006). BMI correlated negatively in CAH females with self-perception (rs = -.64, P = .0338), physical well-being (rs = -.8; P = .0086), social exclusion rs = -.65; P = .031) and emotions (rs = -.7; P = .0169). CONCLUSION Health-related quality of life and body compositions were similar to those of healthy adolescents. Lower scores in HRQoL dimensions as self-perception, physical well-being, social exclusion and emotions were detected and correlated negatively with BMI. Treatment strategies and psychological support should consider HRQoL and adapted in specific treatment guidelines.
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Affiliation(s)
- Janna Mittnacht
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniela Choukair
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Breil
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniela Klose
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Ioana Inta
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Bettendorf
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
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Lajic S, Karlsson L, Zetterström RH, Falhammar H, Nordenström A. The Success of a Screening Program Is Largely Dependent on Close Collaboration between the Laboratory and the Clinical Follow-Up of the Patients. Int J Neonatal Screen 2020; 6:68. [PMID: 33117907 PMCID: PMC7569867 DOI: 10.3390/ijns6030068] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/24/2020] [Indexed: 02/05/2023] Open
Abstract
Neonatal screening for congenital adrenal hyperplasia due to 21-hydroxylase deficiency is now performed in an increasing number of countries all over the world. The main goal of the screening is to achieve early diagnosis and treatment in order to prevent neonatal salt-crisis and death. The screening laboratory can also play an important role in increasing the general awareness of the disease and act as the source of information and education for clinicians to facilitate improved initial care, ensure prompt and correct glucocorticoid dosing to optimize the long-term outcome for the patients. A National CAH Registry and CYP21A2 genotyping provide valuable information both for evaluating the screening program and the clinical outcome. The Swedish experience is described.
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Affiliation(s)
- Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-17176 Stockholm, Sweden
| | - Leif Karlsson
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
| | - Rolf H Zetterström
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176 Stockholm, Sweden;
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176 Stockholm, Sweden;
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, SE-17176 Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-17176 Stockholm, Sweden
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
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Kocova M, Anastasovska V, Falhammar H. Clinical outcomes and characteristics of P30L mutations in congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Endocrine 2020; 69:262-277. [PMID: 32367336 PMCID: PMC7392929 DOI: 10.1007/s12020-020-02323-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/18/2020] [Indexed: 01/07/2023]
Abstract
Despite numerous studies in the field of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, some clinical variability of the presentation and discrepancies in the genotype/phenotype correlation are still unexplained. Some, but not all, discordant phenotypes caused by mutations with known enzyme activity have been explained by in silico structural changes in the 21-hydroxylase protein. The incidence of P30L mutation varies in different populations and is most frequently found in several Central and Southeast European countries as well as Mexico. Patients carrying P30L mutation present predominantly as non-classical CAH; however, simple virilizing forms are found in up to 50% of patients. Taking into consideration the residual 21-hydroxulase activity present with P30L mutation this is unexpected. Different mechanisms for increased androgenization in patients carrying P30L mutation have been proposed including influence of different residues, accompanying promotor allele variability or mutations, and individual androgene sensitivity. Early diagnosis of patients who would present with SV is important in order to improve outcome. Outcome studies of CAH have confirmed the uniqueness of this mutation such as difficulties in phenotype classification, different fertility, growth, and psychologic issues in comparison with other genotypes. Additional studies of P30L mutation are warranted.
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Affiliation(s)
- Mirjana Kocova
- Medical Faculty, University"Cyril&Methodius", Skopje, Republic of North Macedonia
| | - Violeta Anastasovska
- Genetic Laboratory, University Pediatric Hospital, Skopje, Republic of North Macedonia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Kamenický P, Blanchard A, Lamaziere A, Piedvache C, Donadille B, Duranteau L, Bry H, Gautier JF, Salenave S, Raffin-Sanson ML, Genc S, Pietri L, Christin-Maitre S, Thomas J, Lorthioir A, Azizi M, Chanson P, Le Bouc Y, Brailly-Tabard S, Young J. Cortisol and Aldosterone Responses to Hypoglycemia and Na Depletion in Women With Non-Classic 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2020; 105:5569997. [PMID: 31529070 DOI: 10.1210/clinem/dgz005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 09/06/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Non-classic 21-hydroxylase deficiency is usually diagnosed in post-pubertal women because of androgen excess. Indication of systematic steroid replacement therapy is controversial because the risk of acute adrenal insufficiency is unknown. In order to specify this risk we evaluated the cortisol and aldosterone secretions in response to appropriate pharmacologic challenges. METHODS In this prospective case-control non-inferiority study we investigated 20 women with non-classic 21-hydroxylase deficiency carrying biallelic CYP21A2 mutations and with serum 17-hydroxyprogesterone (17OHP) >10 ng/mL after stimulation with Synacthen® (tetracosactrin) and 20 age- and body mass index-matched healthy women with 17OHP after Synacthen® <2 ng/mL. Each participant underwent sequentially an insulin tolerance test to evaluate cortisol secretion and a sodium depletion test, obtained by oral administration of 40 mg of furosemide under low sodium diet (<20 mmol during 24 hours), to evaluate renin and aldosterone secretion. FINDINGS The peak serum cortisol concentration after insulin hypoglycemia was lower in patients than in controls (mean difference -47 ng/mL, 90% CI, -66, P = 0.0026). A peak serum cortisol above a cutoff value of 170 ng/mL was obtained in all controls but only in 55% of patients (P = 0.0039). Twenty-four hours after sodium depletion, blood pressure, plasma sodium, potassium, and serum aldosterone concentrations were comparable between the two groups, but patients had higher stimulated renin concentrations than controls (P = 0.0044). INTERPRETATION Patients with non-classic 21-hydroxylase deficiency frequently display partial cortisol insufficiency and compensated defect in aldosterone secretion. Their clinical management should systematically include assessment of adrenal functions.
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Affiliation(s)
- Peter Kamenický
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Univ Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (Inserm) UMR_S1185, Le Kremlin Bicêtre, France
| | - Anne Blanchard
- Centre d'Investigation Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Antonin Lamaziere
- Plateforme de Métabolomique, Peptidomique et de Dosage de Médicaments, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Céline Piedvache
- Unité de Recherche Clinique, Hôpital de Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Bruno Donadille
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Lise Duranteau
- UF de Gynécologie Adolescente et Jeune Adulte, Hôpital de Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Hélène Bry
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Jean-François Gautier
- Centre Universitaire de Diabétologie et de ses Complications, Hôpital Lariboisière, AP-HP, Paris, France
| | - Sylvie Salenave
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | | | - Seray Genc
- Service d'Endocrinologie, Hôpital Jean Bernard, Valenciennes Cedex, France
| | - Laurence Pietri
- Service d'Endocrinologie, Hôpital Saint-Joseph, Paris, France
| | - Sophie Christin-Maitre
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Julien Thomas
- Plateforme de Métabolomique, Peptidomique et de Dosage de Médicaments, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Aurelien Lorthioir
- Centre d'Investigation Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- Unité d'Hypertension, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Michel Azizi
- Centre d'Investigation Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- Unité d'Hypertension, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Philippe Chanson
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Univ Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (Inserm) UMR_S1185, Le Kremlin Bicêtre, France
| | | | - Sylvie Brailly-Tabard
- Univ Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital de Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Jacques Young
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Univ Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (Inserm) UMR_S1185, Le Kremlin Bicêtre, France
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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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Engels M, Span PN, van Herwaarden AE, Sweep FCGJ, Stikkelbroeck NMML, Claahsen-van der Grinten HL. Testicular Adrenal Rest Tumors: Current Insights on Prevalence, Characteristics, Origin, and Treatment. Endocr Rev 2019; 40:973-987. [PMID: 30882882 DOI: 10.1210/er.2018-00258] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022]
Abstract
This review provides the reader with current insights on testicular adrenal rest tumors (TARTs), a complication in male patients with congenital adrenal hyperplasia (CAH). In recent studies, an overall TART prevalence of 40% (range, 14% to 89%) in classic patients with CAH is found. Reported differences are mainly caused by the method of detection and the selected patient population. Biochemically, histologically, and molecularly, TARTs exhibit particular adrenal characteristics and were therefore thought to originate from aberrant adrenal cells. More recently, TARTs have been found to also exhibit testicular characteristics. This has led to the hypothesis of pluripotent cells as the origin of TARTs. High concentrations of ACTH could cause hyperplasia of these pluripotent cells, as TARTs appear to be associated with poor hormonal control with concomitant elevated ACTH. Unfortunately, as yet there are no methods to prevent the development of TARTs, nor are there guidelines to treat patients with TARTs. Intensified glucocorticoid treatment could improve fertility status in some cases, although studies report contradicting results. TARTs can also lead to irreversible testicular damage, and therefore semen cryopreservation could be offered to patients with TARTs. Further research should focus on the etiology and pharmacological treatment to prevent TART development or to treat TARTs and improve the fertility status of patients with TARTs.
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Affiliation(s)
- Manon Engels
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N Span
- Department of Radiation Oncology, Radiotherapy and OncoImmunology Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Piskinpasa H, Ciftci Dogansen S, Kusku Cabuk F, Guzey D, Sahbaz NA, Akdeniz YS, Mert M. BILATERAL ADRENAL AND TESTICULAR MASS IN A PATIENT WITH CONGENITAL ADRENAL HYPERPLASIA. ACTA ENDOCRINOLOGICA-BUCHAREST 2019; -5:113-117. [PMID: 31149069 DOI: 10.4183/aeb.2019.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction Congenital adrenal hyperplasia (CAH) autosomal recessive disorders characterized by impaired adrenal steroid hormone synthesis. The most common form is 21-hydroxylase deficiency (21OHD). Testicular adrenal rest tumors (TARTs) are benign intratesticular masses that occur in male patients with CAH. TARTs are quite common in patients with 21OHD who were diagnosed late. Case report A 41-year-old male patient with CAH secondary to 21OHD. The patient was referred to our endocrinology department from the andrology clinic for bilateral adrenal masses. Bilateral orchiectomy had been performed due to bilateral testicular masses and azoospermia two years ago. The pathology was reported as Leydig cell tumor. In hormonal assessment, baseline cortisol levels were low, 17-hydroxyprogesterone levels with baseline and after cosyntropin stimulation test were high. As a result of clinic and laboratory assessment, the patient was diagnosed with simple virilising CAH due to 21OHD and adrenal insufficiency. Then, prednisolone replacement was initiated. Bilateral orchiectomy tissue blocks of the patient were re-assessed and were considered TART. Magnetic resonance imaging revealed bilateral adrenal masses with 88x55 mm on the right and 41x22 mm on the left. Laparoscopic right adrenalectomy was applied and pathology was reported as myelolipoma. Follow-up of the mass on the left adrenal gland is ongoing. The patient is monitored under prednisolone and testosterone replacement therapy. Early diagnosis of CAH is very important because of the complications it causes. It should be considered especially for bilateral testicular and/or adrenal masses. Both fertility and adrenal glands can be protected with an early diagnosis and an early glucocorticoid replacement.
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Affiliation(s)
- H Piskinpasa
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
| | - S Ciftci Dogansen
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
| | - F Kusku Cabuk
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Pathology, Istanbul, Turkey
| | - D Guzey
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of General Surgery, Istanbul, Turkey
| | - N A Sahbaz
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of General Surgery, Istanbul, Turkey
| | - Y S Akdeniz
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
| | - M Mert
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
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Fouques C, Fatfouta I, Hieronimus S, Sadoul JL, Bongain A. Two cases of male patients followed for a classical form of congenital adrenal hyperplasia (CAH), presenting an azoospermia: analysis and review of the literature. Basic Clin Androl 2019; 29:10. [PMID: 31143447 PMCID: PMC6532123 DOI: 10.1186/s12610-019-0084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Congenital hyperplasia of the adrenal glands is a rare pathology, which can have an impact on male fertility. We report 2 cases of azoospermia in patients followed for a classical form of congenital adrenal hyperplasia. Cases presentation 1st case: After 18 months of infertility of the couple, explorations showed a high level of ACTH on the hormonal biological analysis. A therapeutic strategy combining hydrocortisone with dexamethasone induced a normal semen analysis, and the female partner of the patient subsequently had three spontaneous pregnancies.2nd case: After two years of infertility of the couple, explorations showed adrenal testicular inclusions invading the 4/5th of the testis with a hypergonadotropic hypogonadism, the therapeutic reinforcement did not allow the improvement of semen analysis. Discussion Sertolian deficiency can be explained by: gonadotropic deficiency by excess of adrenal androgens and adrenal testicular lesions (risk of major spermatic alteration). Conclusion Congenital hyperplasia of the adrenal glands is a rare pathology in the context of male infertility. A semen analysis could be performed after puberty and a semen preservation may be proposed.
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Affiliation(s)
- Clélia Fouques
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Imène Fatfouta
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Sylvie Hieronimus
- 2Departments of Endocrinology, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Jean-Louis Sadoul
- 2Departments of Endocrinology, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - André Bongain
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
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Breil T, Yakovenko V, Inta I, Choukair D, Klose D, Mittnacht J, Schulze E, Alrajab A, Grulich-Henn J, Bettendorf M. Typical characteristics of children with congenital adrenal hyperplasia due to 11β-hydroxylase deficiency: a single-centre experience and review of the literature. J Pediatr Endocrinol Metab 2019; 32:259-267. [PMID: 30817301 DOI: 10.1515/jpem-2018-0298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/30/2018] [Indexed: 11/15/2022]
Abstract
Background 11β-hydroxylase deficiency (11βOHD) is a rare disease representing the second most common cause of congenital adrenal hyperplasia (CAH) (5-8%) with an incidence of about 1:100,000. In contrast to 21-hydroxylase deficiency (21OHD), 11βOHD is not included in neonatal screening programmes. The objective of this study was to demonstrate the typical features of male patients with 11βOHD. Methods Clinical, biochemical and radiological data of patients with 11βOHD were analysed in this retrospective single-centre analysis. Results Six male patients of four unrelated families with 11βOHD were identified (0.1-13.5 years of chronological age [CA] at diagnosis). The predominant symptoms were arterial hypertension, tall stature and precocious pseudopuberty. Bone ages (BAs) were remarkably advanced at diagnosis in four index patients (median difference BA-CA: 5.5 years, range 1.5-9.2 years). Homozygous mutations were identified in exon 7 (c.1179_1180dupGA [p.Asn394Argfs*37]) and exon 8 (c.1398+2T>C) of the CYP11B1 gene leading both to a complete loss of function. The latter mutation has not yet been described in databases. 11βOHD was identified by the measurement of 11-deoxycortisol in a newborn screening card of one patient retrospectively. Testicular adrenal rest tumours (TARTs) were detected in three patients at 3.7 years, 11 years and 14.4 years. Conclusion The diagnosis of CAH due to 11βOHD is delayed and should be suspected in children with arterial hypertension, tall stature and precocious pseudopuberty. Patients may develop TARTs as early as infancy. 11βOHD should be included in newborn screening programmes, at least in newborns of index families, to allow early diagnosis and the start of treatment to reduce morbidity.
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Affiliation(s)
- Thomas Breil
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Vira Yakovenko
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Ioana Inta
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniela Choukair
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniela Klose
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Janna Mittnacht
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Egbert Schulze
- Molecular Laboratory, Prof. F. Raue, Heidelberg, Germany
| | - Abdul Alrajab
- Division of Paediatric Radiology, Department of Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Grulich-Henn
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Bettendorf
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
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36
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Al Alawi AM, Nordenström A, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 3β-hydroxysteroid dehydrogenase type 2 deficiency. Endocrine 2019; 63:407-421. [PMID: 30719691 PMCID: PMC6420607 DOI: 10.1007/s12020-018-01835-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE 3β-hydroxysteroid dehydrogenase type 2 deficiency (3βHSD2D) is a very rare variant of congenital adrenal hyperplasia (CAH) causing less than 0.5% of all CAH. The aim was to review the literature. METHODS PubMed was searched for relevant articles. RESULTS 3βHSD2D is caused by HSD3B2 gene mutations and characterized by impaired steroid synthesis in the gonads and the adrenal glands and subsequent increased dehydroepiandrosterone (DHEA) concentrations. The main hormonal changes observed in patients with 3βHSD2D are elevated ratios of the Δ5-steroids over Δ4-steroids but molecular genetic testing is recommended to confirm the diagnosis. Several deleterious mutations in the HSD3B2 gene have been associated with salt-wasting (SW) crisis in the neonatal period, while missense mutations have been associated with a non-SW phenotype. Boys may have ambiguous genitalia, whereas girls present with mild or no virilization at birth. The existence of non-classic 3βHSD2D is controversial. In an acute SW crisis, the treatment includes prompt rehydration, correction of hypoglycemia, and parenteral hydrocortisone. Similar to other forms of CAH, glucocorticoid and mineralocorticoid replacement is needed for long-term management. In addition, sex hormone replacement therapy may be required if normal progress through puberty is failing. Little is known regarding possible negative long-term consequences of 3βHSD2D and its treatments, e.g., fertility, final height, osteoporosis and fractures, adrenal and testicular tumor risk, and mortality. CONCLUSION Knowledge is mainly based on case reports but many long-term outcomes could be presumed to be similar to other types of CAH, mainly 21-hydroxylase deficiency, although in 3βHSD2D it seems to be more difficult to suppress the androgens.
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Affiliation(s)
- Abdullah M Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Division of Medicine, 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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Rosenbaum D, Gallo A, Lethielleux G, Bruckert E, Levy BI, Tanguy ML, Dulon J, Dahmoune N, Salem JE, Bittar R, Leban M, Girerd X, Touraine P, Bachelot A. Early central blood pressure elevation in adult patients with 21-hydroxylase deficiency. J Hypertens 2019; 37:175-181. [PMID: 30036269 DOI: 10.1097/hjh.0000000000001850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Controversial data exist on cardiovascular damages in patients with congenital adrenal hyperplasia (CAH). OBJECTIVE To assess blood pressure and early cardiovascular damages on a large cohort of adult CAH patients and control individuals. DESIGN Case-control study. SETTING Referral Center for Rare Disease, Pitié Salpêtrière Hospital, Paris, France. PATIENTS OR OTHER PARTICIPANTS Fifty-eight women and 26 men with CAH diagnosed in childhood and 85 controls matched-paired for sex, age and smoking status were prospectively included. INTERVENTION Measurement of large arteries and microcirculatory anatomical and functional indices as well as hormonal status and cardiovascular risk factors evaluation. MAIN OUTCOME MEASURE The primary objective was to compare carotid intima-media thickness (cIMT) in CAH patients and controls. The secondary objectives were to compare blood pressure (BP), radial augmentation index (rAI), central BP, carotid-femoral pulse wave velocity (PWV), skin microcirculation indices and inflammation parameters in CAH patients and controls. RESULTS Although PWV and cIMT were identical in patients and controls, higher rAI (64.6 ± 1.7 vs. 59.9 ± 1.6%, P = 0.02) and higher central SBP (101.8 ± 1.5 vs. 95.1 ± 1.5 mmHg, P < 0.001) were observed in CAH patients. Regarding microcirculatory indices, there was a higher functional resting capacity and a lower anatomical capillary density in CAH patients. In multivariate analysis, we found an independant association between CAH and central SBP elevation. CONCLUSION We found an early rise in central SBP in CAH patients whereas sublinical arterial damages markers were normal. Our study suggest that vascular damages and increased cardiovascular risk could be mainly BP-driven.
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Affiliation(s)
- David Rosenbaum
- AP-HP, Endocrinology - Metabolism and Prevention of Cardiovascular Diseases, Groupe Hospitalier Pitié-Salpêtrière - Université Pierre et Marie Curie
- Sorbonne Universités, UPMC Univ Paris 06, INSERM 1146 - CNRS 7371, Laboratoire d'imagerie Biomédicale, F-75013
- Imaging Core Lab, Institute of Cardiometabolism and Nutrition
| | - Antonio Gallo
- AP-HP, Endocrinology - Metabolism and Prevention of Cardiovascular Diseases, Groupe Hospitalier Pitié-Salpêtrière - Université Pierre et Marie Curie
- Sorbonne Universités, UPMC Univ Paris 06, INSERM 1146 - CNRS 7371, Laboratoire d'imagerie Biomédicale, F-75013
- Imaging Core Lab, Institute of Cardiometabolism and Nutrition
| | - Gaelle Lethielleux
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN
| | - Eric Bruckert
- AP-HP, Endocrinology - Metabolism and Prevention of Cardiovascular Diseases, Groupe Hospitalier Pitié-Salpêtrière - Université Pierre et Marie Curie
- Sorbonne Universités, UPMC Univ Paris 06, INSERM 1146 - CNRS 7371, Laboratoire d'imagerie Biomédicale, F-75013
- Imaging Core Lab, Institute of Cardiometabolism and Nutrition
- Dyslipoproteinemia and Atherosclerosis Research Unit, UMRS 939, National Institute for Health and Medical Research (INSERM) and Pierre et Marie Curie University (UPMC - Paris VI)
| | - Bernard I Levy
- AP-HP, Physiologie clinique - Explorations fonctionnelles Lariboisière Hospital
| | | | - Jérôme Dulon
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN
| | - Nora Dahmoune
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN
| | - Joe Elie Salem
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421
- INSERM, CIC-1421 and UMR ICAN 1166
- Sorbonne Universités
- UPMC Univ Paris 06
| | - Randa Bittar
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Hormonal Biochemistry, Paris, France
| | - Monique Leban
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Hormonal Biochemistry, Paris, France
| | - Xavier Girerd
- AP-HP, Endocrinology - Metabolism and Prevention of Cardiovascular Diseases, Groupe Hospitalier Pitié-Salpêtrière - Université Pierre et Marie Curie
- Sorbonne Universités, UPMC Univ Paris 06, INSERM 1146 - CNRS 7371, Laboratoire d'imagerie Biomédicale, F-75013
- Imaging Core Lab, Institute of Cardiometabolism and Nutrition
- Dyslipoproteinemia and Atherosclerosis Research Unit, UMRS 939, National Institute for Health and Medical Research (INSERM) and Pierre et Marie Curie University (UPMC - Paris VI)
| | - Philippe Touraine
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN
- Sorbonne Universités
- UPMC Univ Paris 06
| | - Anne Bachelot
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, ICAN
- Sorbonne Universités
- UPMC Univ Paris 06
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Improda N, Barbieri F, Ciccarelli GP, Capalbo D, Salerno M. Cardiovascular Health in Children and Adolescents With Congenital Adrenal Hyperplasia Due to 21-Hydroxilase Deficiency. Front Endocrinol (Lausanne) 2019; 10:212. [PMID: 31031703 PMCID: PMC6470198 DOI: 10.3389/fendo.2019.00212] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/18/2019] [Indexed: 12/18/2022] Open
Abstract
Increasing evidence indicates that adults with Congenital Adrenal Hyperplasia (CAH) may have a cluster of cardiovascular (CV) risk factors. In addition, ongoing research has highlighted that children and adolescents with CAH are also prone to developing unfavorable metabolic changes, such as obesity, hypertension, insulin resistance, and increased intima-media thickness, which places them at a higher risk of developing CV disease in adulthood. Moreover, CAH adolescents may exhibit subclinical left ventricular diastolic dysfunction and impaired exercise performance, with possible negative consequences on their quality of life. The therapeutic management of patients with CAH remains a challenge and current treatment regimens do not always allow optimal biochemical control. Indeed, overexposure to glucocorticoids and mineralocorticoids, as well as to androgen excess, may contribute to the development of unfavorable metabolic and CV abnormalities. Long-term prospective studies on large cohorts of patients will help to clarify the pathophysiology of metabolic alterations associated with CAH. Meanwhile, further efforts should be made to optimize treatment and identify new therapeutic approaches to prevent metabolic derangement and improve long-term health outcomes of CAH patients.
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Affiliation(s)
- Nicola Improda
- Pediatric Section, Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Flavia Barbieri
- Pediatric Section, Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Gian Paolo Ciccarelli
- Pediatric Section, Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Donatella Capalbo
- Department of Pediatrics, Federico II University of Naples, Naples, Italy
| | - Mariacarolina Salerno
- Pediatric Section, Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
- *Correspondence: Mariacarolina Salerno
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39
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Magkou D, Do Cao C, Bouvattier C, Douillard C, de Marcellus C, Cazabat L, Gérard M, Raffin-Sanson ML, Young J. Foetal exposure to mitotane/Op'DDD: Post-natal study of four children. Clin Endocrinol (Oxf) 2018; 89:805-812. [PMID: 30222204 DOI: 10.1111/cen.13854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/09/2018] [Accepted: 09/10/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Mitotane/Op'DDD is used in the treatment of adrenocortical carcinoma and for other causes of hypercortisolism. Mitotane inhibits cortisol secretion and displays adrenolytic and antitumor actions. This compound is a metabolite of the pesticide and endocrine disruptor DDT (dichlorodiphenyltrichloroethane) and is classified among teratogenic compounds worldwide. However, little is known about its effects on human development. DESIGN The outcome of four children exposed to mitotane during their intrauterine life was examined. PATIENTS Patients having conceived while taking mitotane, or with detectable mitotane plasma levels, were retrospectively recruited via the French COMETE and FIRENDO networks. MEASUREMENTS Mitotane in maternal plasma, adrenocortical hormones in children. RESULTS Three women treated with mitotane gave birth to four children. During early pregnancy, all patients had detectable mitotane plasma levels (0.9, 2.4 and 6.7 mg/L, respectively). During pregnancy, no foetal malformations were detected. The four exposed newborns presented at birth with apparently normal adrenal function and genitalia. One twin female had a low birthweight. Evaluation at birth and after 3 months, 2 years and 7 years of follow-up showed no significant neurological abnormality. Evaluation of adrenocortical functions showed no cortisol deficiency. CONCLUSIONS Unexpectedly, exposure of these four children to mitotane during foetal life seemed to have no clear teratogenic effect. However, considering the sub-therapeutic mitotane concentrations used here, the small number of cases, and because long-term follow-up is unknown, we strongly advise not to take mitotane during pregnancy and still recommend avoiding pregnancy, at least as long as mitotane plasma levels remain detectable.
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Affiliation(s)
- Dimitra Magkou
- Department of Endocrinology and Nutrition, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt, France
| | - Christine Do Cao
- Department of Endocrinology Centre Hospitalier, Universitaire de Lille, Lille, France
| | - Claire Bouvattier
- Université Paris Sud, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Department of Pediatrics, Le Kremlin Bicêtre, France
| | - Claire Douillard
- Department of Endocrinology Centre Hospitalier, Universitaire de Lille, Lille, France
| | - Capucine de Marcellus
- Department of Endocrinology and Nutrition, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt, France
- INSERM U1173, Université de Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France
| | - Laure Cazabat
- Department of Endocrinology and Nutrition, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt, France
- INSERM U1173, Université de Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France
- French Adrenal Cancer Network (COMETE-Cancer) and FIRENDO Network, France
| | - Maxime Gérard
- Department of Pediatrics, Centre Hospitalier Universitaire Ambroise Paré, AP-HP, Boulogne Billancourt, France
| | - Marie-Laure Raffin-Sanson
- Department of Endocrinology and Nutrition, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt, France
- INSERM U1173, Université de Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France
- French Adrenal Cancer Network (COMETE-Cancer) and FIRENDO Network, France
| | - Jacques Young
- Department of Reproductive Endocrinology, Univ Paris Sud, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin Bicêtre, France
- INSERM U1185, Le Kremlin-Bicêtre, France
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40
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Tajima T. Health problems of adolescent and adult patients with 21-hydroxylase deficiency. Clin Pediatr Endocrinol 2018; 27:203-213. [PMID: 30393437 PMCID: PMC6207803 DOI: 10.1297/cpe.27.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/02/2018] [Indexed: 12/30/2022] Open
Abstract
Twenty-one-hydroxylase deficiency (21-OHD) is one of the most common forms of congenital adrenal hyperplasias. Since the disease requires life-long steroid hormone replacement, transition from pediatric clinical care to adolescent and adult care is necessary. Recently, several studies have shown that morbidity and quality of life in adolescent and adult patients with 21-OHD are impaired by obesity, hypertension, diabetes mellitus, impaired glucose tolerance, dyslipidemia, and osteoporosis. In addition, excess adrenal androgen impairs fertility in both females and males. This mini review discusses the current health problems in adolescent and adult patients with 21-OHD and ways to prevent them.
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Affiliation(s)
- Toshihiro Tajima
- Jichi Medical University Children's Medical Center Tochigi, Tochigi, Japan
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41
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 532] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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42
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Daae E, Feragen KB, Nermoen I, Falhammar H. Psychological adjustment, quality of life, and self-perceptions of reproductive health in males with congenital adrenal hyperplasia: a systematic review. Endocrine 2018; 62:3-13. [PMID: 30128958 PMCID: PMC6153586 DOI: 10.1007/s12020-018-1723-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/12/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Congenital adrenal hyperplasia (CAH) has been shown to potentially affect psychological adjustment. However, most research has focused on females, and knowledge about psychological challenges in males remains sparse. The aim of this systematic review was therefore to assess these in males with CAH. METHODS We systematically searched the OVID Medline, PsycINFO, CINAHL, and Web of Science databases, for articles published up to April 20, 2018, investigating psychological adjustment in males with CAH. RESULTS Eleven studies were included in the review. Three main health domains were identified: psychological and psychiatric health, quality of life (QoL), and self-perceptions of reproductive health. Some studies covered more than one health domain. Seven studies explored psychological adjustment and/or the presence of psychiatric symptoms or disorders. Results indicated that males with CAH had more problems related to internalizing behaviors (negative behaviors directed toward the self) and more negative emotionality compared to reference groups. Six studies examined QoL, five of them reporting reduced QoL compared to reference groups. Three studies explored the impact of fertility and sexual health issues on psychological health with varying results from impaired to normal sexual well-being. CONCLUSIONS CAH seems to have an impact on males' psychological health. However, the number of identified studies was limited, included few participants, and revealed divergent findings, demonstrating the need for larger studies and highlighting a number of methodological challenges that should be addressed by future research.
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Affiliation(s)
- Elisabeth Daae
- Centre for Rare Disorders, Oslo University Hospital HF, Oslo, Norway
| | | | - Ingrid Nermoen
- Department of Endocrinology, Akershus University Hospital HF, Lørenskog, Norway
- Division of Medicine and Laboratory Sciences, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
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43
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Sarfati J, Vatier C, Keller I, Guéchot J, Bellanné-Chantelot C, Christin-Maitre S. Severe Congenital Adrenal Hyperplasia Presenting as Bilateral Testicular Tumors and Azoospermia in the Third Decade of Life. J Endocr Soc 2018; 2:997-1000. [PMID: 30140784 PMCID: PMC6101507 DOI: 10.1210/js.2018-00103] [Citation(s) in RCA: 3] [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: 04/24/2018] [Accepted: 06/28/2018] [Indexed: 11/19/2022] Open
Abstract
Classic forms of 21-hydroxylase deficiency (21OHD) are usually diagnosed at birth by salt wasting or precocious puberty in male patients. Here we report the case of a 32-year-old male patient who presented with azoospermia and bilateral testicular tumors. He was referred to our endocrine unit after testicular surgery. His gonadotropins were undetectable. Liquid chromatography-tandem mass spectrometry revealed a high serum progesterone level, high 17-hydroxyprogesterone (17OHP) (255 ng/mL), and high levels of 17OHP metabolites, suggesting a classic form of 21OHD. His blood pressure was normal. Molecular analysis showed a homozygous large 21-hydroxylase gene (CYP21A2) conversion. Furthermore, an adrenal CT scan revealed voluminous, heterogeneous bilateral and asymmetric adrenal masses containing calcifications. Our case report illustrates the fact that a classic form of 21OHD can be diagnosed in late adulthood, manifested by azoospermia and large adrenal tumors, associated with elevated 17OHP.
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Affiliation(s)
- Julie Sarfati
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France.,Service d'Endocrinologie et Médecine de la Reproduction, Paris, France
| | - Camille Vatier
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France.,Service d'Endocrinologie et Médecine de la Reproduction, Paris, France.,Sorbonne Université, Paris, France
| | | | - Jérome Guéchot
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France.,Laboratoire d'Hormonologie, Paris, France
| | | | - Sophie Christin-Maitre
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France.,Service d'Endocrinologie et Médecine de la Reproduction, Paris, France.,Sorbonne Université, Paris, France
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44
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MacKay D, Nordenström A, Falhammar H. Bilateral Adrenalectomy in Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2018; 103:1767-1778. [PMID: 29554355 DOI: 10.1210/jc.2018-00217] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/09/2018] [Indexed: 02/04/2023]
Abstract
CONTEXT Management of congenital adrenal hyperplasia (CAH) involves suppression of the hypothalamic-pituitary-adrenal axis using supraphysiological doses of exogenous glucocorticoids. This can pose a challenge, with Cushing syndrome a frequent complication of adequate suppression. Bilateral adrenalectomy, with subsequent replacement of glucocorticoids and mineralocorticoids at physiological doses, has been proposed as an alternative therapeutic strategy. OBJECTIVE To review the outcomes after bilateral adrenalectomy for CAH. DATA SOURCES A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 January 2018. STUDY SELECTION Case reports or case series were included if they reported individual patient data from patients with CAH who had undergone bilateral adrenalectomy. DATA EXTRACTION Information regarding the following was extracted: first author, country, sex, age at adrenalectomy, year of adrenalectomy, diagnosis, molecular abnormality, pre- and postoperative biochemistry, pre- and postoperative medications, pre- and postoperative body mass index, indication for adrenalectomy, surgical technique, gross and microscopic adrenal characteristics, follow-up duration, and short- and long-term postoperative outcomes. DATA SYNTHESIS We identified 48 cases of bilateral adrenalectomy for CAH, with patients aged from 4 months to 56 years at surgery. The most common indication for surgery was the inability to control hyperandrogenism/virilization and/or Cushing syndrome (n = 30; 62%). Most patients (n = 34; 71%) reported symptomatic improvement postoperatively, with some cases of short-term (n = 5; 10%) and long-term (n = 13; 27%) adverse outcomes. CONCLUSIONS Bilateral adrenalectomy for CAH appears to be a reasonable therapeutic option for carefully selected patients who have had unsatisfactory outcomes with conventional medical management.
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Affiliation(s)
- Diana MacKay
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, 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, Northern Territory, Australia
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45
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Chaudhari M, Johnson EK, DaJusta D, Nahata L. Testicular adrenal rest tumor screening and fertility counseling among males with congenital adrenal hyperplasia. J Pediatr Urol 2018; 14:155.e1-155.e6. [PMID: 29330018 DOI: 10.1016/j.jpurol.2017.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 11/10/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Reduced fertility is a common potential problem among males with congenital adrenal hyperplasia (CAH), with nearly half experiencing impaired sperm production. The major cause of oligo/azoospermia in CAH is testicular adrenal rest tumors (TARTs). Studies indicate that ultrasound screening for TARTs should begin during childhood, yet it remains unclear whether boys with CAH are routinely screened for TARTs and/or counseled about infertility risk and potential interventions such as fertility testing and/or preservation. OBJECTIVE The purpose of this study was to examine TART screening and fertility counseling practices among boys with CAH. STUDY DESIGN An IRB-approved retrospective chart review was conducted of all males with ICD-9/10 codes for CAH (2007-2016) at a large pediatric academic center to examine: age and indication for diagnosis; age at first and last documented pediatric endocrinology and urology visit; history of ultrasound examinations; and documentation of fertility counseling. RESULTS Forty-six patients were included, of whom 38 had 21-hydroxylase deficiency. Median age at diagnosis was 2 weeks (range 7 days-10 years). Median age at the most recent pediatric endocrinology clinic visit was 14 years (range 2-42 years). Twenty-nine patients were >11 years old (63% of the sample) at the time of the study and 14 of these were >18 years old (30% of the sample). Seven patients (15%) had a screening ultrasound at some point in their care, of whom three had TARTs. Fertility was mentioned in the records of six subjects (13% of the sample). Six of the subjects (13%) had any mention of fertility in their records. None of the patients had biochemical testing or semen analysis to assess gonadal function, and none were offered fertility preservation. Only one patient was seen by a pediatric urologist. DISCUSSION Despite the limitations of a single-center retrospective design, our findings highlight that TART screening and fertility counseling remain underutilized in boys with CAH. There is a need for increased awareness and development of practice guidelines within pediatric urology and endocrinology to address this common and understudied problem. CONCLUSION In addition to a screening ultrasound in puberty and consideration of semen analysis after puberty, these boys may benefit from seeing a pediatric urologist independently or in an interdisciplinary program. Boys with CAH and their families should be educated about infertility risk and potential interventions, with the goal of improving reproductive outcomes in this population.
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Affiliation(s)
- Monika Chaudhari
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniel DaJusta
- Division of Pediatric Urology, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Leena Nahata
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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Kocova M, Janevska V, Anastasovska V. Testicular adrenal rest tumors in boys with 21-hydroxylase deficiency, timely diagnosis and follow-up. Endocr Connect 2018; 7. [PMID: 29531157 PMCID: PMC5887129 DOI: 10.1530/ec-18-0097] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Testicular adrenal rest tumors (TARTs) are found in 30-94% of adult males with congenital adrenal hyperplasia (CAH). We sought to explore TART appearance through yearly ultrasound examination of testes in young boys with CAH, and its association with metabolic control and genetic mutations. METHODS Twenty-five boys with 21-hydroxylase deficiency in the age group 4-18 years diagnosed during the period 2001-2016 were included in the study. ACTH, 17-hydroxyprogesterone, androstenedione and testosterone were measured at 4-month intervals. Growth and BMI were assessed at the time of evaluation. PCR/ACRS method was used for CYP21A2 gene analysis. Testicular ultrasound examination was performed yearly. RESULTS TARTs were detected by ultrasound in 8 children at the age of 6-16 years (13.2 years average). Five had salt-wasting form, two had simple virilizing form and one had non-classic form of CAH. Significant differences in the17OHP and androstenedione levels were detected between the boys, adherent and non-adherent to therapy. Inadequate metabolic control was not different in boys with and without TART (11/17 and 5/8 respectively). No significant difference was detected in the distribution of genetic mutations or adherence to therapy between patients with and without TARTs. One patient had a mutation not reported thus far in TART and another developed leukemia. CONCLUSION TART is not rare in young boys with CAH, irrespective of the specific mutation or metabolic control. Ultrasound screening helps timely diagnosis and adjustment of therapy.
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Affiliation(s)
- Mirjana Kocova
- Department of Endocrinology and GeneticsMedical Faculty, University Pediatric Clinic, Ss. Cyril and Methodius University, Skopje, Republic of Macedonia
| | - Vesna Janevska
- Institute of PathologyMedical Faculty, Ss. Cyril and Methodius University, Skopje, Republic of Macedonia
| | - Violeta Anastasovska
- Genetic LaboratoryMedical Faculty, University Pediatric Clinic, Ss. Cyril and Methodius University, Skopje, Republic of Macedonia
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Engels M, Gehrmann K, Falhammar H, Webb EA, Nordenström A, Sweep FC, Span PN, van Herwaarden AE, Rohayem J, Richter-Unruh A, Bouvattier C, Köhler B, Kortmann BB, Arlt W, Roeleveld N, Reisch N, Stikkelbroeck NMML, Claahsen-van der Grinten HL. Gonadal function in adult male patients with congenital adrenal hyperplasia. Eur J Endocrinol 2018; 178:285-294. [PMID: 29339528 DOI: 10.1530/eje-17-0862] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/15/2018] [Indexed: 11/08/2022]
Abstract
CONTEXT Current knowledge on gonadal function in congenital adrenal hyperplasia (CAH) is mostly limited to single-center/country studies enrolling small patient numbers. Overall data indicate that gonadal function can be compromised in men with CAH. OBJECTIVE To determine gonadal function in men with CAH within the European 'dsd-LIFE' cohort. DESIGN Cross-sectional clinical outcome study, including retrospective data from medical records. METHODS Fourteen academic hospitals included 121 men with CAH aged 16-68 years. Main outcome measures were serum hormone concentrations, semen parameters and imaging data of the testes. RESULTS At the time of assessment, 14/69 patients had a serum testosterone concentration below the reference range; 7 of those were hypogonadotropic, 6 normogonadotropic and 1 hypergonadotropic. In contrast, among the patients with normal serum testosterone (55/69), 4 were hypogonadotropic, 44 normogonadotropic and 7 hypergonadotropic. The association of decreased testosterone with reduced gonadotropin concentrations (odds ratio (OR) = 12.8 (2.9-57.3)) was weaker than the association between serum androstenedione/testosterone ratio ≥1 and reduced gonadotropin concentrations (OR = 39.3 (2.1-732.4)). Evaluation of sperm quality revealed decreased sperm concentrations (15/39), motility (13/37) and abnormal morphology (4/28). Testicular adrenal rest tumor (TART)s were present in 39/80 patients, with a higher prevalence in patients with the most severe genotype (14/18) and in patients with increased current 17-hydroxyprogesterone 20/35) or androstenedione (12/18) serum concentrations. Forty-three children were fathered by 26/113 patients. CONCLUSIONS Men with CAH have a high risk of developing hypothalamic-pituitary-gonadal disturbances and spermatogenic abnormalities. Regular assessment of endocrine gonadal function and imaging for TART development are recommended, in addition to measures for fertility protection.
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Affiliation(s)
- M Engels
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - K Gehrmann
- Klinik für Pädiatrie m.S. Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - H Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - E A Webb
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - A Nordenström
- Department of Women's and Children's Health, Division of Pediatric Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - F C Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - P N Span
- Department of Radiation Oncology, Radiotherapy & OncoImmunology laboratory, RIMLS, Radboud University Medical Center, Nijmegen, the Netherlands
| | - A E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J Rohayem
- Centre of Reproductive Medicine and Andrology, Clinical Andrology, University Hospital Münster, Münster, Germany
| | - A Richter-Unruh
- Centre of Reproductive Medicine and Andrology, Clinical Andrology, University Hospital Münster, Münster, Germany
| | - C Bouvattier
- Endocrinologie Pédiatrique, Centre de Référence des Maladies Rares du Développement Sexuel, Hôpital Bicêtre, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - B Köhler
- Klinik für Pädiatrie m.S. Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - B B Kortmann
- Department of Pediatric Urology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - W Arlt
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - N Roeleveld
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - N Reisch
- Medizinische Klinik IV, Klinikum der Universität München, München, Germany
| | - N M M L Stikkelbroeck
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H L Claahsen-van der Grinten
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
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Falhammar H, Claahsen-van der Grinten H, Reisch N, Slowikowska-Hilczer J, Nordenström A, Roehle R, Bouvattier C, Kreukels BPC, Köhler B. Health status in 1040 adults with disorders of sex development (DSD): a European multicenter study. Endocr Connect 2018; 7:466-478. [PMID: 29490934 PMCID: PMC5861372 DOI: 10.1530/ec-18-0031] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 02/28/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The knowledge about health status in adults with disorder of sex development (DSD) is scarce. DESIGN AND METHODS A cross-sectional observational study in 14 European tertiary centers recruited 1040 participants (717 females, 311 males, 12 others) with DSD. Mean age was 32.4 ± 13.6 year (range 16-75). The cohort was divided into: Turner (n = 301), Klinefelter (n = 224), XY-DSD (n = 222), XX-DSD (excluding congenital adrenal hyperplasia (CAH) and 46,XX males) (n = 21), 46,XX-CAH (n = 226) and 45,X/46,XY (n = 45). Perceived and objective health statuses were measured and compared to European control data. RESULTS In DSD, fair to very good general health was reported by 91.4% and only 8.6% reported (very) bad general health (controls 94.0% and 6.0%, P < 0.0001). Longstanding health issues other than DSD and feeling limited in daily life were reported in 51.0% and 38.6%, respectively (controls 24.5% and 13.8%, P < 0.0001 both). Any disorder except DSD was present in 84.3% (controls 24.6%, P < 0.0001). Males reported worse health than females. In the subgroup analysis, Klinefelter and 46,XX-DSD patients reported bad general health in 15.7% and 16.7%, respectively (Turner 3.2% and CAH 7.4%). Comorbidities were prevalent in all DSD subgroups but Klinefelter and Turner were most affected. Early diagnosis of DSD and a healthy lifestyle were associated with less comorbidities. CONCLUSIONS Overall, general health appeared to be good but a number of medical problems were reported, especially in Klinefelter and Turner. Early diagnosis of DSD and a healthy lifestyle seemed to be important. Lifelong follow-up at specialized centers is necessary.
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Affiliation(s)
- Henrik Falhammar
- Department of EndocrinologyMetabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | | | - Nicole Reisch
- Medizinische Klinik and Poliklinik IVDepartment of Endocrinology, University Hospital Munich, Munich, Germany
| | | | - Anna Nordenström
- Department of Women's and Children's HealthKarolinska Institutet, Stockholm, Sweden
- Department of Paediatric EndocrinologyAstrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Robert Roehle
- Coordinating Center for Clinical StudiesCharité Universitätsmedizin, Berlin, Germany
| | - Claire Bouvattier
- Paris-Sud UniversityOrsay, France
- Department of Pediatric EndocrinologyHôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | | | - Birgit Köhler
- Department of Paediatric Endocrinology and DiabetologyCharité Universitätsmedizin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Donadille B, Houang M, Netchine I, Siffroi JP, Christin-Maitre S. Human 3beta-hydroxysteroid dehydrogenase deficiency associated with normal spermatic numeration despite a severe enzyme deficit. Endocr Connect 2018; 7:395-402. [PMID: 29420188 PMCID: PMC5827574 DOI: 10.1530/ec-17-0306] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/02/2018] [Indexed: 11/24/2022]
Abstract
Human 3 beta-hydroxysteroid dehydrogenase deficiency (3b-HSD) is a very rare form of congenital adrenal hyperplasia resulting from HSD3B2 gene mutations. The estimated prevalence is less than 1/1,000,000 at birth. It leads to steroidogenesis impairment in both adrenals and gonads. Few data are available concerning adult testicular function in such patients. We had the opportunity to study gonadal axis and testicular function in a 46,XY adult patient, carrying a HSD3B2 mutation. He presented at birth a neonatal salt-wasting syndrome. He had a micropenis, a perineal hypospadias and two intrascrotal testes. HSD3B2 gene sequencing revealed a 687del27 homozygous mutation. The patient achieved normal puberty at the age of 15 years. Transition from the paediatric department occurred at the age of 19 years. His hormonal profile under hydrocortisone and fludrocortisone treatments revealed normal serum levels of 17OH-pregnenolone, as well as SDHEA, ACTH, total testosterone, inhibin B and AMH. Pelvic ultrasound identified two scrotal testes of 21 mL each, without any testicular adrenal rest tumours. His adult spermatic characteristics were normal, according to WHO 2010 criteria, with a sperm concentration of 57.6 million/mL (N > 15), 21% of typical forms (N > 4%). Sperm vitality was subnormal (41%; N > 58%). This patient, in contrast to previous reports, presents subnormal sperm parameters and therefore potential male fertility in a 24-years-old patient with severe 3b-HSD deficiency. This case should improve counselling about fertility of male patients carrying HSD3B2 mutation.
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Affiliation(s)
- Bruno Donadille
- Service d'Endocrinologie et Médecine de la ReproductionCentre de Référence des Maladies Endocrines Rares de la Croissance, Hôpital Saint Antoine, Groupe Hospitalier Universitaire Est, AP-HP, Paris, France
| | - Muriel Houang
- Service d'Explorations Fonctionnelles EndocriniennesCentre de Référence des Maladies Endocrines Rares de la Croissance, Hôpital Trousseau, Groupe Hospitalier Universitaire Est, AP-HP, Paris, France
| | - Irène Netchine
- Service d'Explorations Fonctionnelles EndocriniennesCentre de Référence des Maladies Endocrines Rares de la Croissance, Hôpital Trousseau, Groupe Hospitalier Universitaire Est, AP-HP, Paris, France
- Université Pierre et Marie CurieSorbonne Université, Paris, France
| | - Jean-Pierre Siffroi
- Université Pierre et Marie CurieSorbonne Université, Paris, France
- INSERM UMR_S933Paris, France
| | - Sophie Christin-Maitre
- Service d'Endocrinologie et Médecine de la ReproductionCentre de Référence des Maladies Endocrines Rares de la Croissance, Hôpital Saint Antoine, Groupe Hospitalier Universitaire Est, AP-HP, Paris, France
- Université Pierre et Marie CurieSorbonne Université, Paris, France
- INSERM UMR_S933Paris, France
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Tanaka M, Enatsu N, Chiba K, Fujisawa M. Two cases of reversible male infertility due to congenital adrenal hyperplasia combined with testicular adrenal rest tumor. Reprod Med Biol 2018; 17:93-97. [PMID: 29371828 PMCID: PMC5768970 DOI: 10.1002/rmb2.12068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/03/2017] [Indexed: 11/12/2022] Open
Abstract
Cases Testicular adrenal rest tumor (TART) is one of the possible causes of male infertility, accompanied by congenital adrenal hyperplasia (CAH). Here are reported two cases of TARTs that were referred to Kobe City Medical Center West Hospital for the treatment of infertility and testicular tumors. Outcome In one case, the semen analysis was improved from oligoasthenozoospermia to normozoospermia after taking oral glucocorticoid supplementation. The other case of original azoospermia showed that sperm had ejaculated into the semen after taking oral glucocorticoid supplementation. Conclusion Although the prevalence of TARTs in male infertility is very rare, it is important to know how to approach this disease, considering the curable pathology of spermatogenesis and tumors resembling an appearance to germ cell tumors.
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Affiliation(s)
- Mikito Tanaka
- Department of UrologyKobe University Graduate School of MedicineKobe CityJapan
| | - Noritoshi Enatsu
- Division of UrologyKobe City Medical Center West HospitalKobe CityJapan
| | - Koji Chiba
- Department of UrologyKobe University Graduate School of MedicineKobe CityJapan
| | - Masato Fujisawa
- Department of UrologyKobe University Graduate School of MedicineKobe CityJapan
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