1
|
Bulsari K, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Endocrine 2017; 55:19-36. [PMID: 27928728 DOI: 10.1007/s12020-016-1189-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency is a rare autosomal recessive genetic disorder. It is caused by reduced or absent activity of 11β-hydroxylase (CYP11B1) enzyme and the resultant defects in adrenal steroidogenesis. The most common clinical features of 11 beta-hydroxylase deficiency are ambiguous genitalia, accelerated skeletal maturation and resultant short stature, peripheral precocious puberty and hyporeninemic hypokalemic hypertension. The biochemical diagnosis is based on raised serum 11-deoxycortisol and 11-deoxycorticosterone levels together with increased adrenal androgens. More than 100 mutations in CYP11B1 gene have been reported to date. The level of in-vivo activity of CYP11B1 relates to the degree of severity of 11 beta-hydroxylase deficiency. Clinical management of 11 beta-hydroxylase deficiency can pose a challenge to maintain adequate glucocorticoid dosing to suppress adrenal androgen excess while avoiding glucocorticoid-induced side effects. The long-term outcomes of clinical and surgical management are not well studied. This review article aims to collate the current available data about 11 beta-hydroxylase deficiency and its management.
Collapse
Affiliation(s)
- Krupali Bulsari
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
| |
Collapse
|
3
|
Turcu AF, Rege J, Chomic R, Liu J, Nishimoto HK, Else T, Moraitis AG, Palapattu GS, Rainey WE, Auchus RJ. Profiles of 21-Carbon Steroids in 21-hydroxylase Deficiency. J Clin Endocrinol Metab 2015; 100:2283-90. [PMID: 25850025 PMCID: PMC4454804 DOI: 10.1210/jc.2015-1023] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Marked elevations of 17-hydroxyprogesterone (17OHP) are characteristic of classic 21-hydroxylase deficiency (21OHD). Testing of 17OHP provides the basis for 21OHD diagnosis, although it suffers from several pitfalls. False-positive or false-negative results and poor discrimination of nonclassic 21OHD from carriers limit the utility of serum 17OHP and necessitate dynamic testing after cosyntropin stimulation when values are indeterminate. OBJECTIVE The objective was to provide a detailed characterization of 21-carbon (C21) steroids in classic 21OHD, which might identify other candidate steroids that could be employed for the diagnosis of 21OHD. SETTING AND PARTICIPANTS Patients (11 women, 10 men) with classic 21OHD and 21 sex- and age-matched controls seen in a tertiary referral center were studied. METHODS C21 steroids in the peripheral sera from all subjects, as well as in media from cultured testicular adrenal rest tumor (TART) cells and normal adrenal (NA) cells, were analyzed using liquid chromatography/tandem mass spectrometry (10 steroids). Additionally, the dynamics of C21 steroid metabolism in TART and NA cells were assessed with radiotracer studies. RESULTS Five C21 steroids were significantly higher in 21OHD patients: 17OHP (67-fold; P < .01), 21-deoxycortisol (21dF; 35-fold; P < .01), 16α-hydroxyprogesterone (16OHP; 28-fold; P < .01), progesterone (2-fold; P < .01), and 11β-hydroxyprogesterone (11OHP; not detected in controls; P < .01). The same steroids were the highest in media from TART cells relative to the NA cells: 11OHP, 58- to 65-fold; 21dF, 30- to 41-fold; 17OHP, 9-fold; progesterone, 9- to 12-fold; and 16OHP, 7-fold. CONCLUSION Measurement of 16OHP and 11OHP along with 17OHP and 21dF by liquid chromatography/tandem mass spectrometry might comprise a biomarker panel to accurately diagnose all forms of 21OHD.
Collapse
Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Juilee Rege
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Robert Chomic
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Jiayan Liu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Hiromi K Nishimoto
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Andreas G Moraitis
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Ganesh S Palapattu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - William E Rainey
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| |
Collapse
|
4
|
Crocker MK, Barak S, Millo CM, Beall SA, Niyyati M, Chang R, Avila NA, Van Ryzin C, Segars J, Quezado M, Merke DP. Use of PET/CT with cosyntropin stimulation to identify and localize adrenal rest tissue following adrenalectomy in a woman with congenital adrenal hyperplasia. J Clin Endocrinol Metab 2012; 97:E2084-9. [PMID: 22904181 PMCID: PMC3485588 DOI: 10.1210/jc.2012-2298] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Adrenalectomy is an experimental treatment option for select patients with congenital adrenal hyperplasia who have failed medical therapy. After adrenalectomy, adrenal rest tissue can remain in extraadrenal locations, cause recurrent hyperandrogenism, and be difficult to localize. OBJECTIVE The aim of the study was to investigate the usefulness of positron emission tomography/computerized tomography (PET/CT) in identifying adrenal rest tissue. SUBJECT A female with salt-wasting 21-hydroxylase deficiency who had bilateral adrenalectomy at age 17 yr presented with hyperandrogenism at age 32 yr. Pelvic magnetic resonance imaging and ultrasound imaging were nondiagnostic for the source of androgen production. METHODS AND RESULTS A baseline F-18 labeled fluoro-2-deoxy-d-glucose (18F-FDG) PET/CT scan showed no active uptake; however, a second scan preceded by a 250-μg cosyntropin injection identified three areas of active uptake near both ovaries. Subsequent ovarian venous sampling showed elevations in 17-hydroxyprogesterone, androstenedione, and 21-deoxycortisol in both ovarian veins compared to a peripheral vein at baseline and more so after cosyntropin administration. At laparoscopy, three well-circumscribed nodules (2.4 × 0.9 × 1.3 cm, 1.2 × 1.5 × 1.5 cm, and 2 × 1.5 × 1 cm) lying lateral to the fallopian tubes adjacent to the broad ligaments were removed. The paraovarian nodules and previously removed adrenal glands had similar histology and immunohistochemistry. Postoperatively, androgen concentrations were undetectable, with no response to cosyntropin stimulation. CONCLUSIONS Patients with CAH after an adrenalectomy may experience recurrent hyperandrogenism due to adrenal rest tissue. 18F-FDG PET/CT with cosyntropin stimulation accurately identified adrenal rest tissue not visualized with conventional imaging, allowing for successful surgical resection.
Collapse
Affiliation(s)
- Melissa K Crocker
- National Institutes of Health (NIH), The Eunice Kennedy Shriver National Institute of Child Health andHuman Development (M.K.C., J.S., D.P.M.), Bethesda, Maryland 20892, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Papatya Çakır ED, Şentürk Mutlu F, Eren E, Paşa AÖ, Sağlam H, Tarım Ö. Testicular adrenal rest tumors in patients with congenital adrenal hyperplasia. J Clin Res Pediatr Endocrinol 2012; 4:94-100. [PMID: 22672867 PMCID: PMC3386780 DOI: 10.4274/jcrpe.563] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Early diagnosis and treatment of testicular adrenal rest tumors (TART) is important for gonadal functions and fertility protection in boys with congenital adrenal hyperplasia (CAH). In this descriptive study, we investigated the prevalence of TART in boys with 21-hydroxylase deficient (21OHD) CAH followed in our pediatric endocrine clinic. METHODS The study group consisted of 14 male patients with a mean age of 9.6 ± 5.1 (range: 0.8-18.3) years. Six (42.9%) of the 14 patients were diagnosed as having salt-wasting type (SW) and eight (57.1%) patients - as having the simple virilizing (SV) form of 21OHD. Mean age at diagnosis was 2.9 ± 2.7 (range: 0.03-6.3) years. Two different radiologists performed scrotal ultrasonography. Chronological age, bone age, and anthropometric measurements were evaluated. Serum adrenocorticotropic hormone (ACTH), 17-alpha-hydroxyprogesterone (17OHP) and androstenedione levels were also evaluated in all patients during the follow-up period. RESULTS Scrotal ultrasonography revealed bilateral TART in two patients (14.3%) and testicular microlithiasis (TM) in four patients (28.6%). One patient had both TART and TM bilaterally. During the follow-up period, the mean serum adrenocorticotropic hormone, 17OHP and androstenedione levels in the total group of patients were 130.0 ± 179.1 pg/mL (21.7-726.5), 5.8 ± 3.3 ng/mL (0.8-11.4) and 4.3 ± 4.1 (0.2-11.0) ng/mL, respectively. CONCLUSIONS Microlithiasis or TART may be frequently encountered during the follow-up of patients with CAH. In order to prevent late complications including infertility, we suggest that ultrasonographic evaluations be performed yearly in all male CAH patients.
Collapse
Affiliation(s)
| | - Fatma Şentürk Mutlu
- Uludağ University Faculty of Medicine, Department of Radiology, Bursa, Turkey
| | - Erdal Eren
- Uludağ University Faculty of Medicine, Department of Pediatric Endocrinology, Bursa, Turkey
| | - Aliye Özlem Paşa
- Uludağ University Faculty of Medicine, Department of Radiology, Bursa, Turkey
| | - Halil Sağlam
- Uludağ University Faculty of Medicine, Department of Pediatric Endocrinology, Bursa, Turkey
| | - Ömer Tarım
- Uludağ University Faculty of Medicine, Department of Pediatric Endocrinology, Bursa, Turkey
| |
Collapse
|
7
|
Stikkelbroeck NMML, Suliman HM, Otten BJ, Hermus ARMM, Blickman JG, Jager GJ. Testicular adrenal rest tumours in postpubertal males with congenital adrenal hyperplasia: sonographic and MR features. Eur Radiol 2003; 13:1597-603. [PMID: 12835972 DOI: 10.1007/s00330-002-1786-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2002] [Revised: 10/21/2002] [Accepted: 11/25/2002] [Indexed: 11/28/2022]
Abstract
The purpose of this study was to investigate the prevalence of testicular adrenal rest tumours in patients with congenital adrenal hyperplasia (CAH), and to describe sonographic and MR features of these lesions. Seventeen postpubertal male CAH patients underwent scrotal sonography, with colour Doppler, and in 16 of them pre- and postcontrast enhanced T1- and T2-weighted MR images of the testes were obtained. Ultrasound revealed lesions in 16 of 17 patients (94%), bilateral in 10 patients and unilateral in 6 patients. The lesions were typically located adjacent to the mediastinum testis. The maximal diameter of the lesions varied from 2 to 40 mm. Margins were blurred in 11 of 31 lesions. Seventeen of the 20 lesions smaller than 2 cm in diameter were hypoechoic, whereas all 11 lesions larger than 2 cm showed hyperechoic reflections. On MR all lesions were isointense on T1- and hypointense on T2-weighted images and lesion margins were clearly defined. Enhancement of the lesions after intravenous contrast was seen in 13 of 15 patients. In our series the prevalence of testicular adrenal rest tumours in postpubertal CAH patients is much higher than in other reported studies. The lesions may develop from some small, hypoechoic, and multifocal nodules and coalesce to large hypoechoic lesions with hyperechoic reflections on ultrasound. As our results suggest that ultrasonography and MR show the lesions equally well, ultrasonography should be the method of first choice for detection and follow-up of these lesions, because it is the cheapest and quickest imaging technique. In case of a partial orchiectomy, MR is recommended because it shows lesion margins optimally.
Collapse
Affiliation(s)
- Nike M M L Stikkelbroeck
- Department of Paediatric Endocrinology, University Medical Centre Nijmegen, internal post 435, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | | | | | | | | | | |
Collapse
|