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Oriolo C, Fanelli F, Castelli S, Mezzullo M, Altieri P, Corzani F, Pelusi C, Repaci A, Di Dalmazi G, Vicennati V, Baldazzi L, Menabò S, Dormi A, Nardi E, Brillanti G, Pasquali R, Pagotto U, Gambineri A. Steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency in a population of PCOS with suspicious levels of 17OH-progesterone. J Endocrinol Invest 2020; 43:1499-1509. [PMID: 32236851 DOI: 10.1007/s40618-020-01235-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/20/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We aimed at defining the most effective routine immunoassay- or liquid chromatography-tandem mass spectrometry (LC-MS/MS)-determined steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency (21-NCAH) in a PCOS-like population before genotyping. METHODS Seventy PCOS-like patients in reproductive age with immunoassay-determined follicular 17OH-progesterone (17OHP) ≥ 2.00 ng/mL underwent CYP21A2 gene analysis and 1-24ACTH test. Serum steroids were measured by immunoassays at baseline and 60 min after ACTH stimulation; basal steroid profile was measured by LC-MS/MS. RESULTS Genotyping revealed 23 21-NCAH, 15 single allele heterozygous CYP21A2 mutations (21-HTZ) and 32 PCOS patients displaying similar clinical and metabolic features. Immunoassays revealed higher baseline 17OHP and testosterone, and after ACTH stimulation, higher 17OHP (17OHP60) and lower cortisol, whereas LC-MS/MS revealed higher 17OHP (17OHPLC-MS/MS), progesterone and 21-deoxycortisol and lower corticosterone in 21-NCAH compared with both 21-HTZ and PCOS patients. Steroid thresholds best discriminating 21-NCAH from 21-HTZ and PCOS were estimated, and their diagnostic accuracy in identifying 21-NCAH from PCOS was established by ROC analysis. The highest accuracy was observed for 21-deoxycortisol ≥ 0.087 ng/mL, showing 100% sensitivity, while the combination of 17OHPLC-MS/MS ≥ 1.79 ng/mL and corticosterone ≤ 8.76 ng/mL, as well as the combination of ACTH-stimulated 17OHP ≥ 6.77 ng/mL and cortisol ≤ 240 ng/mL by immunoassay, showed 100% specificity. CONCLUSIONS LC-MS/MS measurement of basal follicular 21-deoxycortisol, 17OHP and corticosterone seems the most convenient method for diagnosing 21-NCAH in a population of PCOS with a positive first level screening, providing high accuracy and reducing the need for ACTH stimulation test.
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Affiliation(s)
- C Oriolo
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - F Fanelli
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - S Castelli
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - M Mezzullo
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - P Altieri
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - F Corzani
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - C Pelusi
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - A Repaci
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - G Di Dalmazi
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - V Vicennati
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - L Baldazzi
- Medical Genetic Unit, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - S Menabò
- Medical Genetic Unit, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - A Dormi
- Biostatistics Laboratory, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - E Nardi
- Biostatistics Laboratory, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - G Brillanti
- Biostatistics Laboratory, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - R Pasquali
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - U Pagotto
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - A Gambineri
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
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Chesover AD, Millar H, Sepiashvili L, Adeli K, Palmert MR, Hamilton J. Screening for Nonclassic Congenital Adrenal Hyperplasia in the Era of Liquid Chromatography-Tandem Mass Spectrometry. J Endocr Soc 2019; 4:bvz030. [PMID: 32110745 PMCID: PMC7041698 DOI: 10.1210/jendso/bvz030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022] Open
Abstract
Context Screening for and diagnosing non classic congenital adrenal hyperplasia (NCCAH) uses serum 17-hydroxyprogesterone (17OHP) thresholds established from immunoassay data; however, a new liquid-chromatography tandem mass spectrometry (LC-MS/MS) method results in lower 17OHP values. The evolution of immunoassays is also challenging our diagnostic cut-off for glucocorticoid insufficiency and few data re-evaluate the utility of testing for glucocorticoid insufficiency in NCCAH. Objective (1) Evaluate the 17OHP threshold that predicts NCCAH in children using LC-MS/MS, and (2) determine the prevalence of glucocorticoid insufficiency in NCCAH. Methods A retrospective chart review of pediatric patients who underwent ACTH stimulation tests with cortisol and 17OHP measurements from 2011 to 2018 for assessment of NCCAH. Other adrenal pathologies were excluded. A cortisol < 415 nmol/L defined glucocorticoid insufficiency. Published correlation data determined a 17OHP of 3.3 nmol/L by LC-MS/MS was equivalent to 6 nmol/L by immunoassay. Data analysis was by measures of diagnostic accuracy. Results Of 188 patients included, 23 (12%) had NCCAH (21/23 had genetic confirmation); the remaining 2 had peak 17OHP > 30 nmol/L. Baseline 17OHP ≥ 6 nmol/L most accurately screened for NCCAH—sensitivity and specificity 96%. Almost all genetically confirmed NCCAH (20/21) had peak 17OHP > 30 nmol/L; all subjects with other diagnoses peaked < 30 nmol/L. Glucocorticoid insufficiency was present in 55% with NCCAH. Conclusions Despite the increased specificity of LC-MS/MS, a baseline 17OHP ≥ 6 nmol/L most accurately screened for NCCAH; this supports current practice guidelines. This threshold identified all with glucocorticoid insufficiency, notably prevalent in our cohort and for whom glucocorticoid stress dosing should be considered.
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Affiliation(s)
- Alexander D Chesover
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto M5G 1H4, Canada
| | - Heather Millar
- Section of Gynaecology, Division of Endocrinology, Department of Obstetrics and Gynaecology, The Hospital for Sick Children, University of Toronto M5G 1H4, Toronto, Canada
| | - Lusia Sepiashvili
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto M5G 1H4, Canada
| | - Khosrow Adeli
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto M5G 1H4, Canada
| | - Mark R Palmert
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto M5G 1H4, Canada.,Department of Physiology, University of Toronto, Toronto M5S 1A8, Canada
| | - Jill Hamilton
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto M5G 1H4, Canada
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Livadas S, Bothou C. Management of the Female With Non-classical Congenital Adrenal Hyperplasia (NCCAH): A Patient-Oriented Approach. Front Endocrinol (Lausanne) 2019; 10:366. [PMID: 31244776 PMCID: PMC6563652 DOI: 10.3389/fendo.2019.00366] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/22/2019] [Indexed: 12/02/2022] Open
Abstract
Non-classical congenital adrenal hyperplasia (NCCAH) is considered to be a common monogenic inherited disease, with an incidence range from 1:500 to 1:100 births worldwide. However, despite the high incidence, there is a low genotype-phenotype correlation, which explains why NCCAH diagnosis is usually delayed or even never carried out, since many patients remain asymptomatic or are misdiagnosed as suffering from other hyperandrogenic disorders. For affected adolescent and adult women, it is crucial to investigate any suspicion of NCCAH and determine a firm and accurate diagnosis. The Synacthen test is a prerequisite in the event of clinical suspicion, and molecular testing will establish the diagnosis. In most cases occurring under 8 years of age, the first symptom is premature pubarche. In some cases, due to advanced bone age and/or severe signs of hyperandrogenism, initiation of hydrocortisone treatment prepubertally may be considered. Our unifying theory of the hyperandrogenic signs system and its regulation by internal (hormones, enzymes, tissue sensitivity) and external (stress, insulin resistance, epigenetic, endocrine disruptors) factors is presented in an attempt to elucidate both the prominent genotype-phenotype heterogeneity of this disease and the resultant wide variation of clinical findings. Treatment should be initiated not only to address the main cause of the patient's visit but additionally to decrease abnormally elevated hormone concentrations. Goals of treatment include restoration of regular menstrual cyclicity, slowing the progression of hirsutism and acne, and improvement of fertility. Hydrocortisone supplementation, though not dexamethasone administration, could, as a general rule, be helpful, however, at minimum doses, and also for a short period of time and, most likely, not lifelong. On the other hand, in cases where severe hirsutism and/or acne are present, prescription of oral contraceptives and/or antiandrogens may be advisable. Furthermore, women with NCCAH commonly experience subfertility, therefore, there will be analysis of the appropriate approach for these patients, including during pregnancy, based mainly on genotype. Besides, we should keep in mind that since the same patient will have changing requirements through the years, the attending physician should undertake a tailor-made approach in order to cover her specific needs at different stages of life.
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Affiliation(s)
- Sarantis Livadas
- Metropolitan Hospital, Pireas, Greece
- *Correspondence: Sarantis Livadas
| | - Christina Bothou
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
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Abstract
Congenital adrenal hyperplasia (CAH) is classified as classical CAH and non-classical CAH (NCCAH). In the classical type, the most severe form comprises both salt-wasting and simple virilizing forms. In the non-classical form, diagnosis can be more confusing because the patient may remain asymptomatic or the condition may be associated with signs of androgen excess in the postnatal period or in the later stages of life. This review paper will include information on clinical findings, symptoms, diagnostic approaches, and treatment modules of NCCAH.
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Affiliation(s)
- Selim Kurtoğlu
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey
| | - Nihal Hatipoğlu
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey Phone: +90 505 578 05 37 E-mail:
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Parsa AA, New MI. Steroid 21-hydroxylase deficiency in congenital adrenal hyperplasia. J Steroid Biochem Mol Biol 2017; 165:2-11. [PMID: 27380651 DOI: 10.1016/j.jsbmb.2016.06.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 02/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) refers to a group of inherited genetic disorders involving deficiencies in enzymes that convert cholesterol to cortisol within the adrenal cortex. There are five key enzymes involved in the production of cortisol. Of these key enzymes, deficiency of 21-hydroxylase is the most commonly defective enzyme leading to CAH representing more than 90% of cases. The low adrenal cortisol levels associated with CAH affects the hypothalamic-pituitary-adrenal negative feedback system leading to increased pituitary adrenocorticotropic hormone (ACTH) production, which overstimulates the adrenal cortex in an attempt to increase cortisol production resulting in a hyperplastic adrenal cortex. The deficiency of enzyme 21-hydroxylase results from mutations or deletions in the CYP21A2 gene found on chromosome 6p. The disorder is transmitted as an autosomal recessive pattern and specific mutations may be correlated to enzymatic compromise of varying degrees, leading to the clinical manifestation of 21-hydroxylase deficiency (21-OHD) CAH.
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Affiliation(s)
- Alan A Parsa
- Department of Medicine, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii, United States.
| | - Maria I New
- Adrenal Steroid Disorders Program, Icahn School of Medicine at Mount Sinai, Manhattan, NY, United States
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