1
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Ota T, Katsumata N, Naiki Y, Horikawa R. Novel non-stop variant of the NR0B1 gene in two siblings with adrenal hypoplasia congenita. J Pediatr Endocrinol Metab 2022; 35:1189-1193. [PMID: 35848959 DOI: 10.1515/jpem-2022-0120] [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: 03/06/2022] [Accepted: 06/23/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Mutations in the dosage-sensitive sex reversal-AHC critical region on the X chromosome, gene 1 (DAX-1, officially NR0B1), cause X-linked adrenal hypoplasia congenita (AHC) and hypogonadotropic hypogonadism (HHG). Salt-losing adrenal insufficiency usually occurs during the neonatal period or early childhood. We report a novel non-stop variant of NR0B1 in two siblings and their unusual clinical course. CASE PRESENTATION The proband was a boy who presented with an unusual form of AHC with neonatal onset of growth failure and mild salt loss, but without cutaneous pigmentation or plasma ACTH elevation. His 4-year-old elder brother had been growing healthily, but carried an AHC diagnosis. A non-stop variant of NR0B1 (p.*471K) was demonstrated in the patients and their mother. CONCLUSIONS We identified a novel non-stop variant of NR0B1 in two siblings. Mild salt loss associated with hyperkalemia is a crucial diagnostic clue for AHC, even without apparent symptoms of glucocorticoid deficiency.
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Affiliation(s)
- Tomoko Ota
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Noriyuki Katsumata
- Department of Molecular Endocrinology, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuhiro Naiki
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
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2
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An Update on Genetics of Adrenal Gland and Associated Disorders. ENDOCRINES 2022. [DOI: 10.3390/endocrines3020017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The intricacies of human adrenal development have been under scrutiny for decades. Each year marks the identification of new genes and new interactions between gene products that ultimately will act to produce the fully functioning adult gland. Due to the complexity of this process, genetic missteps may lead to a constellation of pathologies. Recent years have identified several novel genetic causes of adrenal dysgenesis and provided new insights into previously delineated processes. SF1, DAX1 (NR0B1), CDKN1C, SAMD9, GLI3, TPIT, MC2R, MRAP, NNT, TXNRD2, AAAS, and MCM4 are among the genes which have had significant contributions to our understanding of the development and function of both adrenals and gonads. Collection and elucidation of these genetic and clinical insights are valuable tools for clinicians who diagnose and manage cases of adrenal dysfunction.
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3
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Buonocore F, McGlacken-Byrne SM, del Valle I, Achermann JC. Current Insights Into Adrenal Insufficiency in the Newborn and Young Infant. Front Pediatr 2020; 8:619041. [PMID: 33381483 PMCID: PMC7767829 DOI: 10.3389/fped.2020.619041] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
Adrenal insufficiency (AI) is a potentially life-threatening condition that can be difficult to diagnose, especially if it is not considered as a potential cause of a child's clinical presentation or unexpected deterioration. Children who present with AI in early life can have signs of glucocorticoid deficiency (hyperpigmentation, hypoglycemia, prolonged jaundice, poor weight gain), mineralocorticoid deficiency (hypotension, salt loss, collapse), adrenal androgen excess (atypical genitalia), or associated features linked to a specific underlying condition. Here, we provide an overview of causes of childhood AI, with a focus on genetic conditions that present in the first few months of life. Reaching a specific diagnosis can have lifelong implications for focusing management in an individual, and for counseling the family about inheritance and the risk of recurrence.
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Affiliation(s)
| | | | | | - John C. Achermann
- Genetics & Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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4
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Buonocore F, Achermann JC. Primary adrenal insufficiency: New genetic causes and their long-term consequences. Clin Endocrinol (Oxf) 2020; 92:11-20. [PMID: 31610036 PMCID: PMC6916405 DOI: 10.1111/cen.14109] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/03/2019] [Accepted: 10/12/2019] [Indexed: 12/23/2022]
Abstract
Primary adrenal insufficiency (PAI) is a potentially life-threatening condition that requires urgent diagnosis and treatment. Whilst the most common causes are congenital adrenal hyperplasia (CAH) in childhood and autoimmune adrenal insufficiency in adolescence and adulthood, more than 30 other physical and genetics cause of PAI have been reported. Reaching a specific diagnosis can have implications for management and for monitoring associated features, as well as for counselling families about recurrence risk in siblings and relatives. Here, we describe some recent insights into the genetics of adrenal insufficiency and associated molecular mechanisms. We discuss (a) the role of the nuclear receptors DAX-1 (NR0B1) and steroidogenic factor-1 (SF-1, NR5A1) in human adrenal and reproductive dysfunction; (b) multisystem growth restriction syndromes due to gain-of-function in the growth repressors CDKN1C (IMAGE syndrome) and SAMD9 (MIRAGE syndrome), or loss of POLE1; (c) nonclassic forms of STAR and P450scc/CYP11A1 insufficiency that present with a delayed-onset adrenal phenotype and represent a surprisingly prevalent cause of undiagnosed PAI; and (d) a new sphingolipidosis causing PAI due to defects in sphingosine-1-phosphate lyase-1 (SGPL1). Reaching a specific diagnosis can have life-long implications for management. In some situations, milder or nonclassic forms of these conditions can first present in adulthood and may have been labelled, "Addison's disease."
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Affiliation(s)
- Federica Buonocore
- Genetics & Genomic MedicineUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - John C. Achermann
- Genetics & Genomic MedicineUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
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5
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Liu S, Yan L, Zhou X, Chen C, Wang D, Yuan G. Delayed-onset adrenal hypoplasia congenita and hypogonadotropic hypogonadism caused by a novel mutation in DAX1. J Int Med Res 2019; 48:300060519882151. [PMID: 31642359 PMCID: PMC7605007 DOI: 10.1177/0300060519882151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In this study, we described a male who presented with delayed-onset adrenal
hypoplasia congenita (AHC) and mild hypogonadotropic hypogonadism (HHG) without
a relevant family history. A novel mutation in the DAX1
(dosage-sensitive sex reversal, congenital adrenal hypoplasia critical region on
the X chromosome, gene 1) gene was shown to cause X-linked AHC and HHG. Genetic
analysis revealed a novel nonsense mutation, c.154G > T (p.Glu52Term), in the
DAX1 gene. Molecular testing demonstrated that the milder
phenotype caused by this mutation was due to expression of a partially
functional, amino-truncated DAX1 protein generated from an
alternate in-frame translation start site (methionine at codon 83). This unusual
case revealed a potential mechanism for a novel mutation that resulted in an
unusual delayed-onset mild clinical phenotype. It expands the spectrum of
adrenal hypoplasia congenita and hypogonadotropic hypogonadism.
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Affiliation(s)
- Siyue Liu
- Department of Internal Medicine, Tongji Hospital, Huazhong
University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Libin Yan
- Department of Urology, Tongji Hospital, Huazhong University of
Science and Technology, Wuhan, Hubei, P.R. China
| | - Xinrong Zhou
- Department of Internal Medicine, Tongji Hospital, Huazhong
University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Chen Chen
- Molecular Diagnostic Laboratory, Tongji Hospital, Huazhong
University of Science and Technology, Wuhan, Hubei, China
| | - Daowen Wang
- Department of Internal Medicine, Tongji Hospital, Huazhong
University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Gang Yuan
- Department of Internal Medicine, Tongji Hospital, Huazhong
University of Science and Technology, Wuhan, Hubei, P.R. China
- Gang Yuan, Department of Internal Medicine,
Tongji Hospital, Tongji Medical College, Huazhong University of Science &
Technology, Wuhan 430030, China.
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6
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Hyponatremic Seizures and Adrenal Hypoplasia Congenita in a Neonate with Congenital Diaphragmatic Hernia. Case Rep Pediatr 2019; 2019:4178251. [PMID: 31263616 PMCID: PMC6556792 DOI: 10.1155/2019/4178251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/12/2019] [Indexed: 11/18/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) in neonates may occur as an isolated finding, in association with other anomalies, or as part of a genetic syndrome. We report the first case of an infant with CDH who presented with hyponatremic seizures due to adrenal hypoplasia congenita (AHC). The patient underwent repair of CDH defect. After an uncomplicated postoperative course while on discharge planning, he developed a seizure episode associated with severe hyponatremia and hyperkalemia. Extensive diagnostic workup revealed an NR0B1 gene variant confirming the diagnosis of X-linked AHC. The patient was eventually discharged home on hydrocortisone, fludrocortisone, and salt supplements. There are a few case reports of adrenal insufficiency in neonates with CDH, manifesting with symptoms before and immediately after reparative surgery. Clinical presentation of our patient was unique in manifesting as neonatal seizure secondary to severe hyponatremia after a stable postoperative phase. The patient's electrolytes and hemodynamic status remained stable before, during, and after surgery for CDH. This case underlines the importance of taking detailed family history and continued vigilance for signs and symptoms of adrenal insufficiency in infants with repaired CDH by pediatricians and intensivists.
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7
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Guzzetti C, Bizzarri C, Pisaneschi E, Mucciolo M, Bellacchio E, Ibba A, Casula L, Novelli A, Loche S, Cappa M. Next-Generation Sequencing Identifies Different Genetic Defects in 2 Patients with Primary Adrenal Insufficiency and Gonadotropin-Independent Precocious Puberty. Horm Res Paediatr 2019; 90:203-211. [PMID: 30179867 DOI: 10.1159/000492496] [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: 02/19/2018] [Accepted: 07/26/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The development of gonadotropin-independent (peripheral) precocious puberty in male children with primary adrenal insufficiency (PAI) is consistent with a defect in the genes encoding for the enzymes involved in steroid hormone biosynthesis. METHODS Two young boys presented with peripheral precocious puberty followed by PAI. In both patients, the analysis of CYP21A2 gene encoding 21-hydroxylase was normal. As a second step, a targeted next-generation sequencing (NGS) was performed in both patients using a customized panel of congenital endocrine disor ders. RESULTS Case 1 had a new homozygous variant in the CYP11B1 gene (c.1121+5G>A). Mutations of this gene cause congenital adrenal hyperplasia due to 11β-hydroxylase deficiency, an essential enzyme in the cortisol biosynthesis pathway. Case 2 showed a new hemizygous mutation in the NR0B1 gene (c.1091T>G), which encodes for DAX1 (dosage-sensitive sex reversal, adrenal hypoplasia congenita [AHC] and critical region on the X chromosome gene 1). NR0B1 mutations cause X-linked AHC and hypogonadotropic hypogonadism. Pathogenicity prediction software defined both mutations as probably damaging. CONCLUSIONS Peripheral precocious puberty was the atypical presentation of 2 rare genetic diseases. The use of NGS made the characterization of these 2 cases with similar clinical phenotypes caused by 2 different genetic defects possible.
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Affiliation(s)
- Chiara Guzzetti
- Pediatric Endocrine Unit, Pediatric Hospital Microcitemico "Antonio Cao," AO Brotzu, Cagliari, Italy
| | - Carla Bizzarri
- Endocrinology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome,
| | - Elisa Pisaneschi
- Medical Genetics Laboratory, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Mafalda Mucciolo
- Medical Genetics Laboratory, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Emanuele Bellacchio
- Genetic and Rare Diseases, Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anastasia Ibba
- Pediatric Endocrine Unit, Pediatric Hospital Microcitemico "Antonio Cao," AO Brotzu, Cagliari, Italy
| | - Letizia Casula
- Pediatric Endocrine Unit, Pediatric Hospital Microcitemico "Antonio Cao," AO Brotzu, Cagliari, Italy
| | - Antonio Novelli
- Medical Genetics Laboratory, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sandro Loche
- Pediatric Endocrine Unit, Pediatric Hospital Microcitemico "Antonio Cao," AO Brotzu, Cagliari, Italy
| | - Marco Cappa
- Endocrinology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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8
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Rojek A, Krawczynski MR, Jamsheer A, Sowinska-Seidler A, Iwaniszewska B, Malunowicz E, Niedziela M. X-Linked Adrenal Hypoplasia Congenita in a Boy due to a Novel Deletion of the Entire NR0B1 (DAX1) and MAGEB1-4 Genes. Int J Endocrinol 2016; 2016:5178953. [PMID: 27656210 PMCID: PMC5021503 DOI: 10.1155/2016/5178953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/26/2016] [Indexed: 01/01/2023] Open
Abstract
X-linked Adrenal Hypoplasia Congenita (AHC) is caused by deletions or point mutations in the NR0B1 (DAX1) gene. We present a boy with AHC who came at the age of 25 days in a severe state due to prolonged vomiting and progressive dehydration. Laboratory studies showed prominent hyponatremia and hyperkaliemia but not hypoglycemia. Primary adrenal insufficiency was confirmed with low serum cortisol levels and high plasma ACTH levels. Hydrocortisone therapy combined with saline and glucose infusions was started immediately after blood collection. Two exons of the NR0B1 (DAX1) gene were impossible to amplify using the standard PCR method. Array CGH was used to confirm the putative copy-number variation of NR0B1 (DAX1) revealing a novel hemizygous deletion encompassing the entire NR0B1 (DAX1) gene together with the MAGEB genes. This genetic defect was also present in heterozygosity in the patient's mother. We show that NR0B1 (DAX1) gene analysis is important for confirmation of AHC diagnosis and highlights the role of genetic counseling in families with AHC patients, particularly those with X chromosome microdeletions, covering more than NR0B1 (DAX1) alone. We hope that further clinical follow-up of this patient and his family will shed a new light on the role of MAGEB genes.
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Affiliation(s)
- Aleksandra Rojek
- Poznan University of Medical Sciences, 2nd Chair of Pediatrics, Department of Pediatric Endocrinology and Rheumatology, 27/33 Szpitalna Street, 60-572 Poznan, Poland
| | - Maciej R. Krawczynski
- Poznan University of Medical Sciences, Chair and Department of Medical Genetics, Rokietnicka 8 Street, 60-806 Poznan, Poland
- Center for Medical Genetics GENESIS, 4 Grudzieniec Street, Poznan, Poland
| | - Aleksander Jamsheer
- Poznan University of Medical Sciences, Chair and Department of Medical Genetics, Rokietnicka 8 Street, 60-806 Poznan, Poland
- Center for Medical Genetics GENESIS, 4 Grudzieniec Street, Poznan, Poland
| | - Anna Sowinska-Seidler
- Poznan University of Medical Sciences, Chair and Department of Medical Genetics, Rokietnicka 8 Street, 60-806 Poznan, Poland
| | - Barbara Iwaniszewska
- Ludwik Rydygier's Provincial Hospital in Torun, Children's Hospital, Division of Pediatrics, Pediatric Endocrinology and Pediatric Neurology, 42 Konstytucji 3 Maja Street, 87-100 Torun, Poland
| | - Ewa Malunowicz
- The Children's Memorial Health Institute, Department of Laboratory Diagnostics, 20 Al. Dzieci Polskich, 04-736 Warsaw, Poland
| | - Marek Niedziela
- Poznan University of Medical Sciences, 2nd Chair of Pediatrics, Department of Pediatric Endocrinology and Rheumatology, 27/33 Szpitalna Street, 60-572 Poznan, Poland
- Karol Jonscher's Clinical Hospital, 27/33 Szpitalna Street, 60-572 Poznan, Poland
- *Marek Niedziela:
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9
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Suntharalingham JP, Buonocore F, Duncan AJ, Achermann JC. DAX-1 (NR0B1) and steroidogenic factor-1 (SF-1, NR5A1) in human disease. Best Pract Res Clin Endocrinol Metab 2015; 29:607-19. [PMID: 26303087 PMCID: PMC5159745 DOI: 10.1016/j.beem.2015.07.004] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
DAX-1 (NR0B1) and SF-1 (NR5A1) are two nuclear receptor transcription factors that play a key role in human adrenal and reproductive development. Loss of DAX-1 function is classically associated with X-linked adrenal hypoplasia congenita. This condition typically affects boys and presents as primary adrenal insufficiency in early infancy or childhood, hypogonadotropic hypogonadism at puberty and impaired spermatogenesis. Late onset forms of this condition and variant phenotypes are increasingly recognized. In contrast, disruption of SF-1 only rarely causes adrenal insufficiency, usually in combination with testicular dysgenesis. Variants in SF-1/NR5A1 more commonly cause a spectrum of reproductive phenotypes ranging from 46,XY DSD (partial testicular dysgenesis or reduced androgen production) and hypospadias to male factor infertility or primary ovarian insufficiency. Making a specific diagnosis of DAX-1 or SF-1 associated conditions is important for long-term monitoring of endocrine and reproductive function, appropriate genetic counselling for family members, and for providing appropriate informed support for young people.
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Affiliation(s)
| | - Federica Buonocore
- Genetics & Genomic Medicine, UCL Institute of Child Health, University College London, London, UK.
| | - Andrew J Duncan
- Genetics & Genomic Medicine, UCL Institute of Child Health, University College London, London, UK.
| | - John C Achermann
- Genetics & Genomic Medicine, UCL Institute of Child Health, University College London, London, UK.
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10
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Ismail HM, Rincon M. X-linked adrenal hypoplasia congenita: a case report and ethical dilemma. Endocr Pract 2014; 20:e126-9. [PMID: 24641931 DOI: 10.4158/ep14033.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Our objective is to present the first case report of X-linked adrenal hypoplasia congenita in a child conceived by a donated egg and which also presented atypically, with initial mineralocorticoid deficiency. METHODS Case report with literature review. RESULTS A late preterm fraternal twin male, conceived by in vitro fertilization of donated eggs, presented shortly after birth with feeding intolerance, hyponatremia, and hyperkalemia. Testing revealed a low aldosterone level, high plasma renin activity, normal cortisol level, and normal 17-hydroxyprogesterone level. He was diagnosed with 18-hydroxylase deficiency based on low 18-hydroxycorticosterone levels and was treated with mineralocorticoid successfully for 17 months. At age 18 months, he presented with dehydration secondary to herpetic gingivostomatitis and was found to be hypoglycemic, hyponatremic, hyperkalemic, and acidotic, with a low serum cortisol level. An adrenocorticotropic hormone (ACTH) stimulation test revealed low levels of all adrenal cortex products, with an elevated ACTH level. He was started on glucocorticoids. Genetic testing confirmed X-linked adrenal hypoplasia congenita (AHC). His asymptomatic fraternal twin underwent genetic testing and the results were negative. The fertility center records indicated that the mother had donated eggs to other families, but none of the children were known to have this disorder. The egg donor was informed but did not pursue genetic testing. CONCLUSION We report a case of X-linked AHC presenting in the context of extraordinary ethical considerations. Our case raises a question unique to the era of assisted reproduction: should routine genetic screening of gamete donors be done for rare but potentially life-threatening conditions?
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Affiliation(s)
- Heba M Ismail
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Marielisa Rincon
- Division of Pediatric Endocrinology, T.C. Thompson Children's Hospital, Chattanooga, Tennessee
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11
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Xu XQ, Feng YY, Yuan WX, Huang K, Liang L, Fu JF. Novel mutations in DAX1 of X-linked adrenal hypoplasia congenita over several generations in one family. Endocr Pract 2013; 19:e105-11. [PMID: 23512386 DOI: 10.4158/ep12368.cr] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE X-linked adrenal hypoplasia congenital (AHC) is a rare disorder caused by mutations in DAX1 gene. We report a case of X-linked AHC in a large family to analyze the pathogenesis of this rare disease and to add to our clinical knowledge of it. METHODS We describe 3-year-old boy's clinical features and laboratory test results, as well as the patient's nuclear family members' clinical symptoms, especially those with features of adrenal insufficiency. Genomic deoxyribonucleic acid (DNA) was extracted from the patient's and the family members' peripheral blood leukocytes, and the coding region and promoter region of DAX1 were directly sequenced. RESULTS A 3-year-old boy who was diagnosed with X-linked AHC presented with atypical symptoms, and his laboratory test results revealed elevated serum adrenocorticotropic hormone levels (ACTH) and decreased serum cortisol levels. Three novel mutations were detected in the DAX1 coding sequence in this family: a missense mutation (c.376G>A, p.Val126Met), a synonymous mutation (c.498G>A, p.Arg166Arg), and a nonsense mutation (c.1225C>T, p. Gln409X). CONCLUSIONS This report describes the familial transmission of AHC over several generations and further expands the number of DAX1 mutations reported in the literature. Early diagnosis and prompt treatment of X-linked AHC are important and may provide a good prognosis.
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Affiliation(s)
- Xiao-qin Xu
- Department of Endocrinology, The Children's Hospital of ZheJiang University School of Medicine, HangZhou, China
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12
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Rojek A, Obara-Moszynska M, Malecka E, Slomko-Jozwiak M, Niedziela M. NR0B1 (DAX1) mutations in patients affected by congenital adrenal hypoplasia with growth hormone deficiency as a new finding. J Appl Genet 2013; 54:225-30. [PMID: 23378245 DOI: 10.1007/s13353-013-0135-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 01/16/2013] [Accepted: 01/17/2013] [Indexed: 10/27/2022]
Affiliation(s)
- Aleksandra Rojek
- Department of Pediatric Endocrinology and Rheumatology, Molecular Endocrinology Laboratory, Poznan University of Medical Sciences, 27/33 Szpitalna Street, 60-572, Poznan, Poland.
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13
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Sánchez-Pacheco M, Moreno-Pérez O, Sánchez-Ortiga R, Picó A, Moreno F. Hipoplasia adrenal congénita e hipogonadismo hipogonadotropo: variabilidad fenotípica de la mutación R267P del gen DAX-1. ACTA ACUST UNITED AC 2012; 59:140-2. [DOI: 10.1016/j.endonu.2011.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 05/24/2011] [Accepted: 05/25/2011] [Indexed: 11/30/2022]
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14
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Jadhav U, Harris RM, Jameson JL. Hypogonadotropic hypogonadism in subjects with DAX1 mutations. Mol Cell Endocrinol 2011; 346:65-73. [PMID: 21672607 PMCID: PMC3185185 DOI: 10.1016/j.mce.2011.04.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 04/07/2011] [Indexed: 11/17/2022]
Abstract
DAX1 (dosage-sensitive sex reversal, adrenal hypoplasia critical region, on chromosome X, gene 1; also known as NROB1, nuclear receptor subfamily 0, group B, member 1) encodes a nuclear receptor that is expressed in embryonic stem (ES) cells, steroidogenic tissues (gonads, adrenals), the ventromedial hypothalamus (VMH), and pituitary gonadotropes. Humans with DAX1 mutations develop an X-linked syndrome referred to as adrenal hypoplasia congenita (AHC). These boys typically present in infancy with adrenal failure but later fail to undergo puberty because of hypogonadotropic hypogonadism (HHG). The adrenal failure reflects a developmental abnormality in the transition of the fetal to adult zone, resulting in glucocorticoid and mineralocorticoid deficiency. The etiology of HHG involves a combined and variable deficiency of hypothalamic GnRH secretion and/or pituitary responsiveness to GnRH resulting in low LH, FSH and testosterone. Treatment with exogenous gonadotropins generally does not induce spermatogenesis. Animal models indicate that DAX1 also plays a critical role in testis development and function. As a nuclear receptor, DAX1 has been shown to function as a transcriptional repressor, particularly of pathways regulated by other nuclear receptors, such as steroidogenic factor 1 (SF1). In addition to reproductive tissues, DAX1 is also expressed at high levels in ES cells and plays a role in the maintenance of pluripotentiality. Here we review the clinical manifestations associated with DAX1 mutations as well as the evolving information about its function based on animal models and in vitro studies.
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Affiliation(s)
| | | | - J. Larry Jameson
- Corresponding author: J. Larry Jameson, MD, PhD, Vice-President for Medical Affairs and Lewis Landsberg Dean, Northwestern University Feinberg School of Medicine, Arthur J. Rubloff Building, 420 East Superior St., 12th floor, Chicago, IL 60611, , Ph: 312-503-0340; Fax: 312-503-7757
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15
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Landau Z, Hanukoglu A, Sack J, Goldstein N, Weintrob N, Eliakim A, Gillis D, Sagi M, Shomrat R, Kosinovsky EB, Anikster Y. Clinical and genetic heterogeneity of congenital adrenal hypoplasia due to NR0B1 gene mutations. Clin Endocrinol (Oxf) 2010; 72:448-54. [PMID: 19508677 DOI: 10.1111/j.1365-2265.2009.03652.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION X-linked adrenal hypoplasia congenita (AHC) is a rare disorder caused by mutations or complete deletion of the NR0B1 gene that encodes the DAX-1 protein, an orphan member of the nuclear receptor superfamily. AHC is characterized by adrenal insufficiency in infancy and early childhood. Later, hypogonadotropic hypogonadism (HH) manifests as pubertal failure. PATIENTS AND METHODS We evaluated the clinical, endocrine and molecular characteristics of 12 AHC patients from 5 families diagnosed between 1984 and 2007 in Israel. RESULTS Most of the boys (10/12) presented with signs of adrenal insufficiency such as salt wasting and failure to thrive during the neonatal period. Aldosterone deficiency usually preceded cortisol deficiency requiring early mineralocorticoid therapy. Serum cortisol levels in the first weeks of life varied from very low to high levels (<2.76 to >1776 nmol/l). Five boys showed signs of precocious sexual development during infancy and childhood, including enlargement of the penis and testes. In four patients the initial diagnoses were erroneous. Molecular analysis of the NR0B1 gene identified point mutations in six patients including a novel splice site mutation in one patient and his family (IVS1-1G-->C). Contiguous gene deletion was found in six patients from two families who manifested impaired mental development. CONCLUSIONS In X-linked AHC caused by different molecular defects in NR0B1 gene, the clinical spectrum of the disease is quite variable and precocious sexual development is a prominent feature. Genetic testing is indicated in boys presenting with salt-wasting with or without cortisol deficiency if congenital adrenal hyperplasia has been ruled out.
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Affiliation(s)
- Zohar Landau
- Division of Pediatric Endocrinology, E. Wolfson Medical Center, Holon and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
IMPORTANCE OF THE FIELD DAX-1 (NR0B1) is an unusual orphan nuclear receptor whose function is essential for the development of the human adrenal cortex and onset of puberty. Recent data have implicated this transcription factor also in embryonic stem cell and cancer biology. AREAS COVERED IN THIS REVIEW The role of DAX-1 in the regulation of development and function of the adrenal cortex, reproductive axis, embryonic stem cells and a few types of cancer. WHAT THE READER WILL GAIN Here we review the past and present milestones in DAX-1 research and try to provide hints about the development and fields of application of DAX-1-targeted drugs in the future. TAKE HOME MESSAGE The unusual structure and restricted expression pattern of DAX-1 may offer unique opportunities for drug discovery.
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Affiliation(s)
- Enzo Lalli
- Institut de Pharmacologie Moléculaire et Cellulaire CNRS UMR 6097, Valbonne, France.
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Mantovani RM, Pezzuti IL, Dias VMA, Silva IN. Identification of a novel mutation in DAX1/NR0B1A gene in two siblings with severe clinical presentation of adrenal hypoplasia congenita. ACTA ACUST UNITED AC 2009; 53:771-6. [DOI: 10.1590/s0004-27302009000600013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 07/11/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE: To search for mutations in DAX1/NR0B1A gene in siblings to establish the molecular etiology of the adrenal hypoplasia congenita (AHC), a rare potentially life-threatening disorder. CASE REPORT: We describe two siblings who presented with salt-wasting syndrome in the newborn period and received hormonal replacement for primary adrenal insufficiency. A diagnostic hypothesis of AHC was suspected because the children maintained, during hormonal treatment, low plasma 17-OH progesterone (17-OHP) and androgens, despite high ACTH levels. RESULTS: DAX1 gene was studied by molecular analysis, which showed a mutation, confirming the diagnosis in the siblings and a heterozygous state in the mother. Direct sequencing of DAX1 revealed an insertion of an adenine base (c1382-1383 A ins), which lead to a pMet461Asp substitution. CONCLUSION: A novel frameshift mutation of DAX1 gene, which established the molecular etiology of the AHC in the siblings, was identified. Obtaining a precise genetic diagnosis of this adrenal disorder, which, sometimes, cannot be confirmed only by clinical aspects, may have important implications for the long-term management of the disease.
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Shaikh MG, Boyes L, Kingston H, Collins R, Besley GTN, Padmakumar B, Ismayl O, Hughes I, Hall CM, Hellerud C, Achermann JC, Clayton PE. Skewed X inactivation is associated with phenotype in a female with adrenal hypoplasia congenita. J Med Genet 2008; 45:e1. [PMID: 18762570 PMCID: PMC2602739 DOI: 10.1136/jmg.2007.055129] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Adrenal hypoplasia congenita (AHC) can occur due to deletions or mutations in the DAX 1 (NR0B1) gene on the X chromosome (OMIM 300200). This form of AHC is therefore predominantly seen in boys. Deletion of the DAX 1 gene can also be part of a larger contiguous deletion including the centromeric dystrophin and glycerol kinase (GK) genes. We report a girl with a de novo deletion at Xp21.2 on the maternal chromosome, including DAX1, the GK gene and 3′ end of the dystrophin gene, who presented with salt losing adrenal insufficiency and moderate developmental delay, but relatively mild features of muscular dystrophy. Investigation using the androgen receptor as a marker gene identified skewed inactivation of the X chromosome. In the patient’s leucocytes, the paternal X chromosome was completely inactive, but in muscle 20% of the active chromosomes were of paternal origin. Thus skewed X inactivation (deletion on the active maternal X chromosome with an inactive paternal X chromosome) is associated with AHC in a female. Variability in X inactivation between tissues may account for the pronounced salt loss and adrenal insufficiency but mild muscular dystrophy.
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Affiliation(s)
- M G Shaikh
- Department of Endocrinology, Royal Manchester Children's Hospital, Manchester, M27 4HA, UK
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Kim HG, Bhagavath B, Layman LC. Clinical manifestations of impaired GnRH neuron development and function. Neurosignals 2008; 16:165-82. [PMID: 18253056 DOI: 10.1159/000111561] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Gonadotropin-releasing hormone (GnRH) and olfactory neurons migrate together in embryologic development, and disruption of this process causes idiopathic hypogonadotropic hypogonadism (IHH) with anosmia (Kallmann syndrome (KS)). Patients with IHH/KS generally manifest irreversible pubertal delay and subsequent infertility due to deficient pituitary gonadotropins or GnRH. The molecular basis of IHH/KS includes genes that: (1) regulate GnRH and olfactory neuron migration; (2) control the synthesis or secretion of GnRH; (3) disrupt GnRH action upon pituitary gonadotropes, or (4) interfere with pituitary gonadotropin synthesis or secretion. KS patients may also have midline facial defects indicating the diverse developmental functions of genes involved. Most causative genes cause either normosmic IHH or KS except FGFR1, which may cause either phenotype. Recently, several balanced chromosomal translocations have been identified in IHH/KS patients, which could lead to the identification of new disease-producing genes. Although there are two cases reported who have digenic disease, this awaits confirmation in future larger studies. The challenge will be to determine the importance of these genes in the 10-15% of couples with normal puberty who have infertility.
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Affiliation(s)
- Hyung-Goo Kim
- Department of Obstetrics and Gynecology, Institute of Molecular Medicine and Genetics, Medical College of Georgia, Augusta, GA 30912-3360, USA
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Mericq V, Ciaccio M, Marino R, Lamoglia JJ, Viterbo G, Rivarola MA, Belgorosky A. A new DAX-1 mutation in a family with a case of neonatal adrenal insufficiency and a sibling with adrenal hypoplasia and sudden death at 3 years of age. J Pediatr Endocrinol Metab 2007; 20:1039-43. [PMID: 18038713 DOI: 10.1515/jpem.2007.20.9.1039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Adrenal hypoplasia congenita (AHC) is a hereditary disorder that leads to adrenal insufficiency and hypogonadotropic hypogonadism (HHG) in childhood. The gene responsible for the X-linked form of AHC, DAX1 (dosage-sensitive sex-reversal, AHC, on the X-chromosome, gene 1)/NR0B1, encodes for a nuclear factor which lacks the characteristic zinc finger DNA-binding domain that is highly conserved in nuclear receptors. Deletions and point mutations in the DAX1 gene have been described in more than 70 AHC families. We present the clinical and genetic data of two brothers affected by AHC. We report a new DAX1 gene mutation in a family with two affected members: one with neonatal adrenal insufficiency, and a sibling with adrenal hypoplasia and sudden death at 3 years old. The NR0B1/DAX1 gene was amplified in three PCR fragments from the patient's and mother's gDNA extracted from peripheral lymphocytes. Sequencing revealed a novel single nucleotide deletion in codon 419 from exon 2 that resulted in a frameshift and a stop codon 17 nucleotides downstream (c.1256 delA). The mother was heterozygous for this mutation. In conclusion, a novel DAX-1 mutation was detected in two family members with different phenotype: one live infant with adrenal hypoplasia, his mother, and probably his dead brother.
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Affiliation(s)
- Verónica Mericq
- Institute of Maternal and Child Research, Faculty of Medicine, University of Chile, Santiago.
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Ahmad I, Paterson WF, Lin L, Adlard P, Duncan P, Tolmie J, Achermann JC, Donaldson MD. A novel missense mutation in DAX-1 with an unusual presentation of X-linked adrenal hypoplasia congenita. HORMONE RESEARCH 2007; 68:32-7. [PMID: 17308433 PMCID: PMC3479083 DOI: 10.1159/000099835] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Accepted: 12/19/2006] [Indexed: 12/29/2022]
Abstract
A male presented at age 2.2 years with a 6-week history of intermittent vomiting and hyperpigmentation. Investigations showed salt wasting with hyperkalaemia, a grossly impaired cortisol response to ACTH stimulation, elevated renin and ACTH. Family history revealed that two maternal uncles had died soon after birth. A third uncle failed to thrive during infancy but improved with a course of cortisone, then being untreated until further investigation revealed adrenal insufficiency. A fourth uncle died aged 10 days, with urinary salt loss and hypoplastic adrenal glands at postmortem. Molecular studies on the proband, his mother, maternal grandmother, and surviving uncle showed a novel C to G substitution at nucleotide position 794 (missense mutation T265R) in the DAX1 (NR0B1) gene. The proband has responded well to steroid replacement but has proved sensitive to 9alpha-fludrocortisone treatment, developing hypertension on a dose of 133 microg/m(2)/day. At 8.8 years he was noted to have testicular volumes of 4 ml, despite no other evidence of secondary sexual development and prepubertal gonadotrophin levels. Novel features of this family include a novel DAX1 mutation, marked variability in age of presentation, hypertension on 'standard' doses of 9alpha-fludrocortisone and mild testicular enlargement.
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Affiliation(s)
- Imran Ahmad
- Department of Child Health, Royal Hospital for Sick Children, Yorkhill, Glasgow
| | - Wendy F. Paterson
- Department of Child Health, Royal Hospital for Sick Children, Yorkhill, Glasgow
| | - Lin Lin
- Department of Endocrinology, UCL Institute of Child Health, University College London, London
| | | | | | - John Tolmie
- Ferguson-Smith Centre for Clinical Genetics, Royal Hospital for Sick Children, Yorkhill, Glasgow
| | - John C. Achermann
- Department of Endocrinology, UCL Institute of Child Health, University College London, London
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Lin L, Gu WX, Ozisik G, To WS, Owen CJ, Jameson JL, Achermann JC. Analysis of DAX1 (NR0B1) and steroidogenic factor-1 (NR5A1) in children and adults with primary adrenal failure: ten years' experience. J Clin Endocrinol Metab 2006; 91:3048-54. [PMID: 16684822 PMCID: PMC1865080 DOI: 10.1210/jc.2006-0603] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary adrenal failure is a life-threatening condition that can be caused by a range of etiologies, including autoimmune, metabolic, and developmental disorders. The nuclear receptors DAX1 (NR0B1) and steroidogenic factor-1 (SF1/Ad4BP, NR5A1) play an important role in adrenal development and function, and mutations in these transcription factors have been found in patients with adrenal hypoplasia. OBJECTIVE Our objective was to investigate the prevalence of DAX1 and SF1 mutations in children and adults with primary adrenal failure of unknown etiology (i.e. not caused by congenital adrenal hyperplasia, adrenoleukodystrophy, or autoimmune disease). PATIENTS One hundred seventeen patients were included. Eighty-eight individuals presented in infancy or childhood with adrenal hypoplasia or primary adrenal failure of unknown etiology (n = 64 46,XY phenotypic males; n = 17 46,XY gonadal dysgenesis/impaired androgenization; n = 7 46,XX females). Twenty-nine individuals presented in adulthood with Addison's disease of unknown etiology. METHODS Mutational analysis of DAX1 (NR0B1) (including exon 2alpha/1A) and SF1 (NR5A1) was done by direct sequencing. RESULTS DAX1 mutations were found in 58% (37 of 64) of 46,XY phenotypic boys referred with adrenal hypoplasia and in all boys (eight of eight) with hypogonadotropic hypogonadism and a family history suggestive of adrenal failure in males. SF1 mutations causing adrenal failure were found in only two patients with 46,XY gonadal dysgenesis. No DAX1 or SF1 mutations were identified in the adult-onset group. CONCLUSIONS DAX1 mutations are a relatively frequent cause of adrenal failure in this group of boys. SF1 mutations causing adrenal failure in humans are rare and are more likely to be associated with significant underandrogenization and gonadal dysfunction in 46,XY individuals.
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Affiliation(s)
- Lin Lin
- UCL Institute of Child Health and Department of Medicine, University College London, 30 Guilford Street, London WC1N 1EH, United Kingdom
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Ostermann S, Salvi R, Lang-Muritano M, Voirol MJ, Puttinger R, Gaillard RC, Schoenle E, Pralong FP. Importance of genetic diagnosis of DAX-1 deficiency: example from a large, multigenerational family. HORMONE RESEARCH 2006; 65:163-8. [PMID: 16514244 DOI: 10.1159/000091831] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Accepted: 11/15/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Inactivating mutations of DAX-1 give rise to the X-linked form of adrenal hypoplasia congenita (AHC). Affected fetuses are at risk of early postnatal Addisonian crisis, but the variable phenotypic expression of DAX-1 insufficiency renders this diagnosis challenging. METHODS We describe the familial transmission of AHC over several generations. The proband was diagnosed with adrenal insufficiency at age 3.5 years: molecular analysis revealed a novel, 373-bp deletion including the second exon of DAX-1. Given the familial history of several unexplained deaths in male infants related to the proband via his maternal great-grandmother, we hypothesized that all these boys had been affected with AHC. Another female member of the family being pregnant with a male fetus at the time, we performed DAX-1 analysis on the mother and the newborn. The mother was heterozygous for the deletion, and the newborn hemizygous: he presented an adrenal crisis at 10 days of life, and is now doing well on hormone replacement therapy. CONCLUSION The unfortunate deaths of male infants at each generation of this family underlie the importance of early and precise diagnosis of this rare condition, stressing the value of genetic diagnosis in six potential female carriers of this family entering their reproductive years.
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Choi JH, Shin YL, Kim GH, Kim Y, Park S, Park JY, Oh C, Yoo HW. Identification of novel mutations of the DAX-1 gene in patients with X-linked adrenal hypoplasia congenita. HORMONE RESEARCH 2005; 63:200-5. [PMID: 15860922 DOI: 10.1159/000085557] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Accepted: 03/15/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE X-linked adrenal hypoplasia congenita (AHC) is a condition clinically featuring adrenal insufficiency and hypogonadotropic hypogonadism caused by mutations of DAX-1. This study was undertaken to characterize the molecular defects of DAX-1 in 3 unrelated Korean patients with AHC. PATIENTS AND METHODS Patient 1 is a 6-year-old boy who presented with a salt-losing adrenal crisis in the neonatal period. Patient 2 is a 3-year-old boy who manifested aspiration pneumonia and adrenal insufficiency at the age of 1 month. Patient 3 is a 7-year-old boy who developed an adrenal crisis at the age of 3 days. In each of these patients, DAX-1 was analyzed by direct DNA sequencing after polymerase chain reaction amplification of the entire coding region. RESULTS Direct sequencing of DAX-1 revealed two novel mutations, 1156_1157delCT in patient 1 and another novel nonsense mutation W105X in patient 2. Patient 3 had complete deletion of DAX-1. In patient 3, serum transaminases and creatine kinase levels were elevated while the glycerol kinase activity of leukocytes was decreased. Markedly elevated glycerol excretion was detected by urine organic acid analysis. Patient 3 was diagnosed as Xp21 contiguous gene syndrome associated with deletions of the entire IL1RAPL, GK genes and the C-terminal region of DMD gene. CONCLUSIONS Two novel mutations of DAX-1 were detected in 2 unrelated patients with AHC, and complete deletion of DAX-1 in a patient with Xp21 contiguous gene syndrome who also presented with glycerol kinase deficiency, Duchenne muscular dystrophy, and AHC.
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Affiliation(s)
- Jin-Ho Choi
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Argente J, Ozisik G, Pozo J, Teresa Muñoz M, Soriano-Guillén L, Larry Jameson J. A novel single base deletion at codon 434 (1301delT) of the DAX1 gene associated with prepubertal testis enlargement. Mol Genet Metab 2003; 78:79-81. [PMID: 12559852 DOI: 10.1016/s1096-7192(02)00198-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We have identified a novel DAX1 frameshift mutation (1301delT) at codon 434 in a patient with primary adrenal insufficiency. This 11-day-old boy was admitted to the hospital with hyponatremia, hyperkalemia, and suspected congenital adrenal abnormality. He exhibited severe hypoglycemia, pallor of the skin, buccal and genital hyperpigmentation, hypotension (90/45 mm Hg), anemia, and diarrhea. Although basal gonadotropins were low, and responded minimally to exogenous GnRH, the size of his testes began to increase at age 4 and reached 4.5 mL at the age of 9 years and 8 months. Testosterone levels were prepubertal. These findings further emphasize the variable clinical presentation in children with DAX1 gene mutations and indicate the value of genetic testing in boys with primary adrenal insufficiency.
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Affiliation(s)
- Jesús Argente
- Department of Pediatrics, Autonomous University Medical School, Hospital Universitario Infantil Niño Jesús, Avda. Menéndez Pelayo, 65, E-28009, Madrid, Spain.
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