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Bakkar AA, Alsaedi A, Kamal NM, Althobaiti E, Aboulkhair LA, Almalki AM, Alsalmi SA, Alharthi Q, Abosabie SA, Abosabie SAS. Lipoid Congenital Adrenal Hyperplasia With a Novel StAR Gene Mutation. Clin Med Insights Endocrinol Diabetes 2023; 16:11795514231167059. [PMID: 37255966 PMCID: PMC10226314 DOI: 10.1177/11795514231167059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 03/14/2023] [Indexed: 06/01/2023] Open
Abstract
Lipoid congenital adrenal hyperplasia (LCAH) is characterized by disturbance of adrenal and gonadal steroidogenesis (OMIM:201710). It is caused by mutation in the Steroidogenic Acute Regulatory Protein (StAR). We report a classic case of LCAH in a neonate (46, XY) with phenotypic female genitalia who presented with significant salt loss with a novel homozygous variant mutation c.745-1G>C p. in StAR gene.
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Affiliation(s)
| | | | - Naglaa M Kamal
- Kasr Alainy Faculty of Medicine, Cairo
University, Cairo, Egypt
| | | | | | | | | | | | - Sara A Abosabie
- Faculty of Medicine, Charité –
Universitätsmedizin Berlin, Berlin, Germany
| | - Salma AS Abosabie
- Faculty of Medicine,
Julius-Maximilians-Universität Würzburg, Bavaria, Germany
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Musa SA, Hassan SS, Ahmed AI, Ngwiri T, Fadlalbari GF, Ibrahim AA, Babiker OO, Abdullah MA. Clinical profile, etiology, and diagnostic challenges of primary adrenal insufficiency in Sudanese children: 14-years' experience from a resource limited setting. J Pediatr Endocrinol Metab 2022; 35:231-237. [PMID: 34653327 DOI: 10.1515/jpem-2021-0545] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/27/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Primary adrenal insufficiency (PAI) in children is an uncommon condition. Congenital adrenal hyperplasia (CAH) is the commonest cause followed by autoimmune disorders. Diagnosis and management are challenging especially in resource-limited settings. Studies from Africa are scanty and here we describe for the first time the clinical presentation, possible etiologies, and challenges in diagnosis and management of PAI in a large cohort of Sudanese children. METHODS This was a descriptive hospital-based study where all patients diagnosed with PAI between 2006 and 2020 were reviewed. The diagnosis was based on clinical presentation, low morning cortisol ± high adrenocorticotropic hormone (ACTH), or inadequate response of cortisol to synacthen stimulation. Challenges faced in diagnosis and management were identified. RESULTS From 422 PAI suspected patients, 309 (73.2%) had CAH, and 33 (7.8%) had PAI-like symptoms and were not furtherly discussed. Eighty patients (19%) had fulfilled the study criteria: 29 had Allgrove syndrome, nine auto-immune polyendocrinopathy syndrome, seven adrenoleukodystrophy, and one had an adrenal hemorrhage. Hyperpigmentation was the cardinal feature in 75 (93.8%) while the adrenal crisis was not uncommon. Lack of diagnostic facilities has obscured the etiology in 34 (42.5%) patients. CONCLUSIONS PAI is not uncommon in Sudanese children where genetic causes outweigh the autoimmune ones. Many cases were missed due to nonspecific presentation, lack of awareness, and difficult access to tertiary health care facilities. In addition to the clinical findings, early morning cortisol ± ACTH levels can be used in diagnosis where facilities are limited particularly synacthen stimulation test.
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Affiliation(s)
- Salwa A Musa
- Pediatric Endocrinology Unit, Gaafar Ibn Auf Children Hospital (GIA), Khartoum, Sudan
| | - Samar S Hassan
- Pediatric Endocrinology Unit, Gaafar Ibn Auf Children Hospital (GIA), Khartoum, Sudan
| | - Amna I Ahmed
- Pediatric Endocrinology Unit, Gaafar Ibn Auf Children Hospital (GIA), Khartoum, Sudan.,Department of Pediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | | | - Ghassan F Fadlalbari
- Pediatric Endocrinology Unit, Gaafar Ibn Auf Children Hospital (GIA), Khartoum, Sudan
| | | | | | - Mohamed A Abdullah
- Pediatric Endocrinology Unit, Gaafar Ibn Auf Children Hospital (GIA), Khartoum, Sudan.,Department of Pediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
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Lu W, Zhang T, Zhang L, Wang X, Lv S, Wang J, Ye L, Xiao Y, Dong Z, Wang W, Sun S, Li C, Hu R, Ning G, Ma X. Clinical characteristics of a male child with non-classic lipoid congenital adrenal hyperplasia and literature review. Front Endocrinol (Lausanne) 2022; 13:947762. [PMID: 36407315 PMCID: PMC9666400 DOI: 10.3389/fendo.2022.947762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 10/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Lipoid congenital adrenal hyperplasia (LCAH) is a rare and severe disorder that is caused by mutations in the steroidogenic acute regulatory protein (StAR). Non-classic LCAH is defined as late-onset glucocorticoid deficiency and even complete male external genitalia in 46,XY individuals. However, to date, few cases of non-classic LCAH have been reported. METHODS It was attempted to describe the clinical characteristics of a male child with complete male external genitalia in terms of age of onset, adrenal function, and biochemical indicators. Previously reported cases were also reviewed to investigate the relationship of age of onset with enzymatic activity in non-classic LCAH. RESULTS The patient with complete male external genitalia was diagnosed with non-classic LCAH, in which the reason for his referral to a local hospital at the of age 1.25 years was progressive skin hyperpigmentation, and plasma adrenocorticotropic hormone (ACTH) level was elevated to higher than 1,250 pg/ml. The compound heterozygous mutations c.772C>T/c.562C>T in STAR gene were identified via genetic testing. The literature review resulted in identification of 47 patients with non-classic LCAH from 36 families. The mutational analysis showed that c.562C>T mutation was prevalent in patients with non-classic LCAH, accounting for 37.2% of the total mutant alleles, which could reflect the founder effect on the non-classic LCAH population. In total, 28 46,XY patients were reported, including 22 (78.5%) cases with complete male external genitalia and six (21.5%) cases with different degrees of hypospadias. CONCLUSION The clinical phenotypes of non-classic LCAH are highly variable. Routine physical examination, laboratory measurement, genetic testing, and, importantly, enzymatic activity assay may facilitate the early diagnosis of non-classic LCAH. The age of primary adrenal insufficiency (PAI) onset may not be a diagnostic basis for non-classic LCAH, and enzymatic activity assay determination may be more effective.
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Affiliation(s)
- Wenli Lu
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tingting Zhang
- Department of Pediatric Genetic and Metabolic Endocrinology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lidan Zhang
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xueqing Wang
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sheng Lv
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junqi Wang
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Ye
- Department of Endocrine and Metabolism, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Xiao
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhiya Dong
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Wang
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuoyue Sun
- Department of Endocrine and Metabolism, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuanyin Li
- Cancer Center, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Chuanyin Li, ; Ronggui Hu, ; Guang Ning, ; Xiaoyu Ma,
| | - Ronggui Hu
- Cancer Center, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Chuanyin Li, ; Ronggui Hu, ; Guang Ning, ; Xiaoyu Ma,
| | - Guang Ning
- Department of Endocrine and Metabolism, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Chuanyin Li, ; Ronggui Hu, ; Guang Ning, ; Xiaoyu Ma,
| | - Xiaoyu Ma
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Chuanyin Li, ; Ronggui Hu, ; Guang Ning, ; Xiaoyu Ma,
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Chang Z, Lu W, Zhao Z, Xi L, Li X, Ye R, Ni J, Pei Z, Zhang M, Cheng R, Zheng Z, Sun C, Wu J, Luo F. Genetic aetiology of primary adrenal insufficiency in Chinese children. BMC Med Genomics 2021; 14:172. [PMID: 34193132 DOI: 10.1186/s12920-021-01021-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 06/21/2021] [Indexed: 01/10/2023] Open
Abstract
Background Primary adrenal insufficiency (PAI) is life-threatening, and a definitive aetiological diagnosis is essential for management and prognostication. We conducted this study to investigate the genetic aetiologies of PAI in South China and explore their clinical features. Methods Seventy children were enrolled in this cross-sectional study. Clinical information was collected, and combined genetic tests were performed according to the children’s manifestations. Statistical analysis was performed among the different groups. In silico or in vitro experiments were applied to determine the pathogenicity of novel variants. Results Among the 70 children, 84.3% (59/70) were diagnosed with congenital adrenal hyperplasia (CAH), and 21-hydroxylase deficiency (21-OHD) was genetically confirmed in 91.5% of these cases. Salt wasting (SW), simple virilization (SV), and non-classic (NC) CAH accounted for 66.1% (39/59), 30.5% (18/59), and 3.4% (2/59) of the cases, respectively. The 17-hydroxyprogesterone (17-OHP) and testosterone (TES) levels were significantly higher in children with SW than with SV. The 17-OHP and cortisol levels in female SW patients were significantly higher than those in males. The 17-OHP, cortisol, dehydroepiandrosterone (DHEAS) and TES levels in female SW patients were significantly higher than those in female SV patients. Additionally, 72.7% (8/11) of uncharacterized PAI patients had positive genetic findings. Among all the patients, two novel variants in the CYP21A2 gene (c.833dupT and c.651 + 2T > G) were found. A microdeletion (Xp21.2–21.3) and five novel variants, including 2 in the NR0B1 gene (c.323–324CG > GA and c.1231_1234delCTCA), 2 in the AAAS gene (c.399 + 1G > A and c.250delT) and 1 in the NNT gene (c.2274delT), were detected. The novel variant c.399 + 1G > A in the AAAS gene was further confirmed to lead to exon 4 skipping during mRNA transcription and produce a truncated ALADIN protein. Conclusions We found ethnicity-based differences in the CYP21A2 gene variant spectrum among different study populations. Female 21-OHD patients tended to have higher 17-OHP and TES levels, which warrants caution in relation to the effects of virilization. Novel gene variants detected in the CYP21A2, NR0B1, AAAS and NNT genes expanded the genetic spectrum of PAI, however, further improvement of genetic testing tools beyond our protocol are still needed to uncover the complete aetiology of PAI in children. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-021-01021-x.
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Capalbo D, Moracas C, Cappa M, Balsamo A, Maghnie M, Wasniewska MG, Greggio NA, Baronio F, Bizzarri C, Ferro G, Di Lascio A, Stancampiano MR, Azzolini S, Patti G, Longhi S, Valenzise M, Radetti G, Betterle C, Russo G, Salerno M. Primary Adrenal Insufficiency in Childhood: Data From a Large Nationwide Cohort. J Clin Endocrinol Metab 2021; 106:762-773. [PMID: 33247909 DOI: 10.1210/clinem/dgaa881] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Indexed: 01/01/2023]
Abstract
CONTEXT Primary adrenal insufficiency (PAI) is a rare and potentially life-threatening condition that is poorly characterized in children. OBJECTIVE To describe causes, presentation, auxological outcome, frequency of adrenal crisis and mortality of a large cohort of children with PAI. PATIENTS AND METHODS Data from 803 patients from 8 centers of Pediatric Endocrinology were retrospectively collected. RESULTS The following etiologies were reported: 85% (n = 682) congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD); 3.1% (n = 25) X-linked adrenoleukodystrophy; 3.1% (n = 25) autoimmune polyglandular syndrome type 1; 2.5% (n = 20) autoimmune adrenal insufficiency; 2% (n = 16) adrenal hypoplasia congenital; 1.2% (n = 10) non-21-OHD CAH; 1% (n = 8) rare syndromes; 0.6% (n = 5) familial glucocorticoid deficiency; 0.4% (n = 3) acquired adrenal insufficiency; 9 patients (1%) did not receive diagnosis. Since 21-OHD CAH has been extensively characterized, it was not further reviewed. In 121 patients with a diagnosis other than 21-OHD CAH, the most frequent symptoms at diagnosis were fatigue (67%), hyperpigmentation (50.4%), dehydration (33%), and hypotension (31%). Elevated adrenocorticotropic hormone (96.4%) was the most common laboratory finding followed by hyponatremia (55%), hyperkalemia (32.7%), and hypoglycemia (33.7%). The median age at presentation was 6.5 ± 5.1 years (0.1-17.8 years) and the mean duration of symptoms before diagnosis was 5.6 ± 11.6 months (0-56 months) depending on etiology. Rate of adrenal crisis was 2.7 per 100 patient-years. Three patients died from the underlying disease. Adult height, evaluated in 70 patients, was -0.70 ± 1.20 standard deviation score. CONCLUSIONS We characterized one of the largest cohorts of children with PAI aiming to improve the knowledge on diagnosis of this rare condition.
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Affiliation(s)
- Donatella Capalbo
- Pediatric Endocrinology Unit, Department of Mother and Child, University Hospital Federico II, Endo-ERN Center for Rare Endocrine Conditions, Naples, Italy
| | - Cristina Moracas
- Pediatric Endocrinology Unit, Department of Translational Medical Sciences, University of Naples Federico II, Endo-ERN Center for Rare Endocrine Conditions, Naples, Italy
| | - Marco Cappa
- Unit of Endocrinology, Bambino Gesù Children's Hospital (IRCCS), Rome, Italy
| | - Antonio Balsamo
- Pediatric Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi University Hospital, Endo-ERN Center for Rare Endocrine Conditions, Bologna, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, 16147 Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | | | - Nella Augusta Greggio
- Department of Women's and Children's Health of Padua, Pediatric Endocrinology and Adolescence Unit, Endo-ERN Center for Rare Endocrine Conditions, Padua, Italy
| | - Federico Baronio
- Pediatric Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi University Hospital, Endo-ERN Center for Rare Endocrine Conditions, Bologna, Italy
| | - Carla Bizzarri
- Unit of Endocrinology, Bambino Gesù Children's Hospital (IRCCS), Rome, Italy
| | - Giusy Ferro
- Unit of Endocrinology, Bambino Gesù Children's Hospital (IRCCS), Rome, Italy
| | - Alessandra Di Lascio
- Department of Pediatrics, Endocrine Unit, IRCCS San Raffaele Scientific Institute, Endo-ERN Center for Rare Endocrine Conditions, Milan, Italy
| | - Marianna Rita Stancampiano
- Department of Pediatrics, Endocrine Unit, IRCCS San Raffaele Scientific Institute, Endo-ERN Center for Rare Endocrine Conditions, Milan, Italy
| | - Sara Azzolini
- Department of Women's and Children's Health of Padua, Pediatric Endocrinology and Adolescence Unit, Endo-ERN Center for Rare Endocrine Conditions, Padua, Italy
| | - Giuseppa Patti
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, 16147 Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Silvia Longhi
- Department of Pediatrics, Regional Hospital, Bolzano, Italy
| | - Mariella Valenzise
- Unit of Pediatrics, Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
| | | | - Corrado Betterle
- Unit of Endocrinology, Department of Medicine (DIMED) University of Padua, Padua, Italy
| | - Gianni Russo
- Department of Pediatrics, Endocrine Unit, IRCCS San Raffaele Scientific Institute, Endo-ERN Center for Rare Endocrine Conditions, Milan, Italy
| | - Mariacarolina Salerno
- Pediatric Endocrinology Unit, Department of Translational Medical Sciences, University of Naples Federico II, Endo-ERN Center for Rare Endocrine Conditions, Naples, Italy
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Abstract
OBJECTIVE Primary adrenal insufficiency (PAI) is a rare but potentially life-threatening condition. In childhood, PAI is usually caused by monogenic diseases. Although congenital adrenal hyperplasia (CAH) is the most common cause of childhood PAI, numerous non-CAH genetic causes have also been identified. METHODS Patients aged 0-18 years and diagnosed with PAI between 1998 and 2019 in a tertiary care hospital were retrospectively evaluated. After the etiologic distribution was determined, non-CAH PAI patients were evaluated in detail. RESULTS Seventy-three PAI patients were identified. The most common etiology was CAH (69.9%, n=51). Non-CAH etiologies accounted for 30.1% (n=22) and included adrenoleukodystrophy (ALD; n=8), familial glucocorticoid deficiency (n=3), Triple A syndrome (n=5), autoimmune adrenalitis (n=1), adrenal hypoplasia congenital (n=1), IMAGe syndrome (n=1), and other unknown etiologies (n=3). The median age at the time of AI diagnosis for non-CAH etiologies was 3.52 (0.03-15.17) years. The most frequent symptoms/clinical findings at onset were hyperpigmentation of skin (81.8%), symptoms of hypoglycemia (40.9%), and weakness/fatigue (31.8%). Hypoglycemia (50.0%), hyponatremia (36.4%) and hyperkalemia (22.7%) were prominent biochemical findings. Diagnosis of specific etiologies were proven genetically in 13 of 22 patients. A novel p.Q301* hemizygous frameshift mutation of the DAX1 gene was identified in one patient. CONCLUSION Etiology was determined in 86.3% of children with non-CAH PAI through specific clinical and laboratory findings with/ without molecular analysis of candidate genes. ALD was the most common etiology. Currently, advanced molecular analysis can be utilized to establish a specific genetic diagnosis for PAI in patients who have no specific diagnostic features.
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Affiliation(s)
- Emine Çamtosun
- İnönü University Faculty of Medicine, Department of Pediatric Endocrinology, Malatya, Turkey,* Address for Correspondence: İnönü University Faculty of Medicine, Department of Pediatric Endocrinology, Malatya, Turkey Phone: +90 505 254 17 95 E-mail:
| | - İsmail Dündar
- Malatya Training and Research Hospital, Clinic of Pediatric Endocrinology, Malatya, Turkey
| | - Ayşehan Akıncı
- İnönü University Faculty of Medicine, Department of Pediatric Endocrinology, Malatya, Turkey
| | - Leman Kayaş
- İnönü University Faculty of Medicine, Department of Pediatric Endocrinology, Malatya, Turkey
| | - Nurdan Çiftçi
- İnönü University Faculty of Medicine, Department of Pediatric Endocrinology, Malatya, Turkey
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Sharma S, Murthy SI, Rathi V. Bilateral limbal stem cell disease in a patient with Addison's disease. BMJ Case Rep 2021; 14:e240959. [PMID: 33509896 PMCID: PMC7845711 DOI: 10.1136/bcr-2020-240959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2021] [Indexed: 01/30/2023] Open
Affiliation(s)
- Supriya Sharma
- GPR-ICARE, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | | | - Varsha Rathi
- GPR-ICARE, LV Prasad Eye Institute, Hyderabad, Telangana, India
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Chen H, Zhang Q, Chen R, Yuan X, Lin X, Yang X, Zhang Y. Lipoid congenital adrenal hyperplasia due to steroid acute regulatory protein (STAR) variants in Three Chinese patients. J Steroid Biochem Mol Biol 2020; 200:105635. [PMID: 32068072 DOI: 10.1016/j.jsbmb.2020.105635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 12/18/2022]
Abstract
Congenital adrenal hyperplasia (CAH) encompasses a group of autosomal recessive diseases characterized by enzymatic defects in steroid synthesis. Lipoid congenital adrenal hyperplasia (LCAH) is the most severe form of CAH, insofar as the initial step of steroid synthesis is impaired. Variants in the steroid acute regulatory (STAR) gene are responsible for LCAH. To describe the clinical and genetic characteristics of three Chinese patients with LCAH. We analyzed the history, clinical manifestations, physical examination, laboratory data, and computed tomography findings of three girls with LCAH. The STAR gene of the probands and their parents were sequenced using genomic DNA. The wild-type and mutant STAR cDNAs were inserted into the pcDNA3.1(+) plasmid vector and transiently transfected into COS7 cells. The enzymatic activities of the wild-type and mutant STAR were evaluated by the enzyme-dependent conversion efficiency of cholesterol to pregnenolone. We identified the molecular genetic abnormalities in three patients with LCAH. All three patients had a female phenotype: karyotype of patients 1 and 2 was 46, XY and patient 3 was 46, XX. DNA sequencing revealed compound heterozygous variants in STAR for three probands. Two variants, c.659A > G/p.His220Arg and exon 2-3 deletion, were novel. In vitro functional studies uncovered that the His220Arg variant retained 19.2 % of enzymatic activity compared to that of the wild type.
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Affiliation(s)
- Hong Chen
- Department of Endocrinology, Fuzhou Children's Hospital of Fujian Province, Fujian Medical University Teaching Hospital, Fuzhou, 35005, China; Department of Pediatrics, The First Affiliated Hospital, School of Medicine Zhejiang University, Hangzhou, 310003, China
| | - Qianru Zhang
- Department of Endocrinology, Fuzhou Children's Hospital of Fujian Province, Fujian Medical University Teaching Hospital, Fuzhou, 35005, China; Department of Pediatrics, Affiliated Hospital of Hebei University, Baoding, 071000, China
| | - Ruimin Chen
- Department of Endocrinology, Fuzhou Children's Hospital of Fujian Province, Fujian Medical University Teaching Hospital, Fuzhou, 35005, China.
| | - Xin Yuan
- Department of Endocrinology, Fuzhou Children's Hospital of Fujian Province, Fujian Medical University Teaching Hospital, Fuzhou, 35005, China
| | - Xiangquan Lin
- Department of Endocrinology, Fuzhou Children's Hospital of Fujian Province, Fujian Medical University Teaching Hospital, Fuzhou, 35005, China
| | - Xiaohong Yang
- Department of Endocrinology, Fuzhou Children's Hospital of Fujian Province, Fujian Medical University Teaching Hospital, Fuzhou, 35005, China
| | - Ying Zhang
- Department of Endocrinology, Fuzhou Children's Hospital of Fujian Province, Fujian Medical University Teaching Hospital, Fuzhou, 35005, China
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Wijaya M, Huamei M, Jun Z, Du M, Li Y, Chen Q, Chen H, Song G. Etiology of primary adrenal insufficiency in children: a 29-year single-center experience. J Pediatr Endocrinol Metab 2019; 32:615-622. [PMID: 31141483 DOI: 10.1515/jpem-2018-0445] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 04/01/2019] [Indexed: 11/15/2022]
Abstract
Background Primary adrenal insufficiency (PAI) in children is a rare condition and potentially lethal. The clinical characteristics are non-specific. It may be manifested as a chronic condition or crisis. The etiologies of PAI in children are different from the adult population. Therefore, diagnostic investigation becomes challenging. Methods A retrospective study was conducted at The First Affiliated Sun Yat Sen University Pediatric Endocrine unit between September 1989 and July 2016. Results A total of 434 patients (237 males, 197 females) were identified as having PAI. Congenital adrenal hyperplasia (CAH) was the most frequent etiology (83.4%, n = 362, male:female = 174:188), of which 351 (97.2%) were 21-hydroxylase deficiency (21-OH) CAH. Non-CAH etiology accounted for 11.3% (n = 49, male:female = 47:2), of which 46 (93.9%) were of non-autoimmune. The etiologies of the 49 cases were adrenoleukodystrophy (ALD; n = 22), X-linked adrenal hypoplasia congenital (X-AHC; n = 20), autoimmune polyglandular syndrome (APS; n = 3), triple A syndrome (n = 2), steroidogenic factor 1 (SF-1) gene mutation (n = 1) and adrenalectomy (n = 1). The etiology was not identified for 23 patients (5.3%, male:female =16:7). Clinical symptoms were in accordance with the incidence of genital ambiguity (42.6%), digestive symptoms (vomiting and diarrhea) (35.5%), failure to thrive (26.5%), gonadal-associated symptom (premature puberty, sexual infantilism and amenorrhea) (21.2%), hyperpigmentation (9.7%), adrenal crisis (AC; 4.1%), neurological symptoms (3.2%), fatigue (2.5%) and prolonged jaundice (2.1%). Through physical examination, 58.5% were found to have hyperpigmentation. Conclusions This study spanned 29 years at our institution. The etiology of PAI in children was mostly of congenital forms, which exhibits a wide spectrum of clinical characteristics. For etiological diagnosis, chromosomal karyotyping is recommended for female phenotype patients.
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Affiliation(s)
- Melati Wijaya
- Department of Pediatrics, The First Affiliated of Sun Yat Sen University, Guangzhou, P.R. China
| | - Ma Huamei
- Department of Pediatrics, The First Affiliated of Sun Yat Sen University, No. 58, Zhongshan II Rd., Guangzhou 510080, P.R. China, Phone: +86 20 87755766-8310, Fax: +86 20 87750632
| | - Zhang Jun
- Department of Pediatrics, The First Affiliated of Sun Yat Sen University, Guangzhou, P.R. China
| | - Minlian Du
- Department of Pediatrics, The First Affiliated of Sun Yat Sen University, Guangzhou, P.R. China
| | - Yanhong Li
- Department of Pediatrics, The First Affiliated of Sun Yat Sen University, Guangzhou, P.R. China
| | - Qiuli Chen
- Department of Pediatrics, The First Affiliated of Sun Yat Sen University, Guangzhou, P.R. China
| | - Hongshan Chen
- Department of Pediatrics, The First Affiliated of Sun Yat Sen University, Guangzhou, P.R. China
| | - Guo Song
- Department of Pediatrics, The First Affiliated of Sun Yat Sen University, Guangzhou, P.R. China
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Örnek N, Örnek K, Ogurel T. Limbal stem cell defficiency associated with primary adrenocortical insufficiency. GMS Ophthalmol Cases 2019; 9:Doc02. [PMID: 30828512 PMCID: PMC6381395 DOI: 10.3205/oc000091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective: To report a female patient with bilateral limbal stem cell deficiency (LSCD) due to primary adrenocortical insufficiency (PAI). Methods: Case report Results: A 40-year-old female patient had blurry vision, foreign body sensation, tearing, and photophobia for several years. On examination, corneal epithelial haze, surface irregularity, and superficial neovascularization were observed. There was a dull and irregular reflex from the conjunctivalized corneal surface. Medical history revealed that she had a diagnosis of PAI for 11 years and received hormone replacement (fludrocortisone acetate) therapy. With the clinical presentation and examination, the diagnosis was compatible with LSCD. Frequent ocular lubricant and topical steroid drops were initially started and topical cyclosporine treatment was planned for the long term. After 3 weeks, there was no corneal superficial neovascularization and epithelial haze, peripheral stromal haze was still observed. Conclusion: LSCD may rarely be associated with PAI. In patients with LSCD, systemic evaluation should be made to rule out PAI.
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Affiliation(s)
- Nurgül Örnek
- Department of Ophthalmology, School of Medicine, Kırıkkale University, Yahşihan, Turkey
| | - Kemal Örnek
- Department of Ophthalmology, Kudret Eye Hospital, Ankara, Turkey
| | - Tevfik Ogurel
- Department of Ophthalmology, School of Medicine, Kırıkkale University, Yahşihan, Turkey
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11
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Abstract
Primary adrenal insufficiency (PAI) is a life-threatening disorder of adrenal cortex which is characterized by deficient biosynthesis of glucocorticoids, with or without deficiency in mineralocorticoids and adrenal androgens. Typical manifestations of primary adrenal insufficiency include hyperpigmentation, hypotension, hypoglycaemia, hyponatremia with or without hyperkalemia that are generally preceded by nonspecific symptoms at the onset. Recessively inherited monogenic disorders constitute the largest group of primary adrenal insufficiency in children. The diagnostic process of primary adrenal insufficiency includes demonstration of low cortisol concentrations along with high plasma ACTH and identifying the cause of the disorder. Specific molecular diagnosis is achieved in more than 80% of children with PAI by detailed clinical and biochemical characterization integrated with advanced molecular tools. Hormone replacement therapy determined on the type and the severity of deficient adrenocortical hormones is the mainstay of treatment. Optimized methods of steroid hormone delivery, improved monitoring of hormone replacement along with intensive education of patients and families on the rules during intercurrent illness and stress will significantly reduce the morbidity and mortality associated with primary adrenal insufficiency.
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Affiliation(s)
- Tarik Kirkgoz
- Marmara University School of Medicine, Department of Paediatric Endocrinology and Diabetes, Istanbul, Turkey.
| | - Tulay Guran
- Marmara University School of Medicine, Department of Paediatric Endocrinology and Diabetes, Istanbul, Turkey.
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12
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Proust-Lemoine E, Reynaud R, Delemer B, Tabarin A, Samara-Boustani D. Group 3: Strategies for identifying the cause of adrenal insufficiency: diagnostic algorithms. Annales d'Endocrinologie 2017; 78:512-524. [DOI: 10.1016/j.ando.2017.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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13
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Chanson P, Guignat L, Goichot B, Chabre O, Boustani DS, Reynaud R, Simon D, Tabarin A, Gruson D, Reznik Y, Raffin Sanson ML. Group 2: Adrenal insufficiency: screening methods and confirmation of diagnosis. Annales d'Endocrinologie 2017; 78:495-511. [DOI: 10.1016/j.ando.2017.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Bizzarri C, Pisaneschi E, Mucciolo M, Pedicelli S, Galeazzi D, Novelli A, Cappa M. Lipoid congenital adrenal hyperplasia by steroidogenic acute regulatory protein (STAR) gene mutation in an Italian infant: an uncommon cause of adrenal insufficiency. Ital J Pediatr 2017. [PMID: 28637490 PMCID: PMC5480121 DOI: 10.1186/s13052-017-0371-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Lipoid congenital adrenal hyperplasia (CAH) (OMIM n. 201710) is the most severe form of congenital adrenal hyperplasia. It is characterized by severe adrenal and gonadal steroidogenesis impairment due to a defect in the conversion of cholesterol to pregnenolone. Affected infants experience salt loss, but glucocorticoid and mineralocorticoid replacement therapy enables long-term survival. Classic lipoid congenital adrenal hyperplasia is relatively common in Japan and Korea but extremely rare in Caucasian populations. Case presentation A female infant of Italian origin came to our attention in late infancy with a clinical picture of acute adrenal insufficiency. The study of the STAR gene revealed two genomic variants c.562C > T and c.577C > T in compound heterozygosity. At the protein level, the two mutations determine the p.Arg188Cys variant (rs104894090) and the p.Arg193Ter variant (rs387907235), respectively. Sanger sequencing was used to confirm the identified variants and to perform familial study. The mother carried the p.Arg188Cys variant, while the father carried the p.Arg193Ter variant. Conclusion To our knowledge this is the second case of classic lipoid congenital adrenal hyperplasia reported in the Italian population. STAR mutations resulting in lipoid congenital adrenal hyperplasia should be considered all over the world in the differential diagnosis of newborn babies and infants with primary adrenal insufficiency.
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Affiliation(s)
- Carla Bizzarri
- Unit of Endocrinology and Diabetes, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - 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
| | - Stefania Pedicelli
- Unit of Endocrinology and Diabetes, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Daniela Galeazzi
- Pediatric Department, Azienda Unità Sanitaria Locale Umbria 2, Narni (Terni), Italy
| | - Antonio Novelli
- Medical Genetics Laboratory, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - Marco Cappa
- Unit of Endocrinology and Diabetes, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
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15
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Abstract
Steroidogenesis begins with cellular internalization of low-density lipoprotein particles and subsequent intracellular processing of cholesterol. Disorders in these steps include Adrenoleukodystrophy, Wolman Disease and its milder variant Cholesterol Ester Storage Disease, and Niemann-Pick Type C Disease, all of which may present with adrenal insufficiency. The means by which cholesterol is directed to steroidogenic mitochondria remains incompletely understood. Once cholesterol reaches the outer mitochondrial membrane, its delivery to the inner mitochondrial membrane is regulated by the steroidogenic acute regulatory protein (StAR). Severe StAR mutations cause classic congenital lipoid adrenal hyperplasia, characterized by lipid accumulation in the adrenal, adrenal insufficiency, and disordered sexual development in 46,XY individuals. The lipoid CAH phenotype, including spontaneous puberty in 46,XX females, is explained by a two-hit model. StAR mutations that retain partial function cause a milder, non-classic disease characterized by glucocorticoid deficiency, with lesser disorders of mineralocorticoid and sex steroid synthesis. Once inside the mitochondria, cholesterol is converted to pregnenolone by the cholesterol side-chain cleavage enzyme, P450scc, encoded by the CYP11A1 gene. Rare patients with mutations of P450scc are clinically and hormonally indistinguishable from those with lipoid CAH, and may also present as milder non-classic disease. Patients with P450scc defects do not have the massive adrenal hyperplasia that characterizes lipoid CAH, but adrenal imaging may occasionally fail to distinguish these, necessitating DNA sequencing.
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Affiliation(s)
- Walter L Miller
- Center for Reproductive Sciences, University of California, San Francisco, CA 94143-0556, United States.
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16
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Bizzarri C, Olivini N, Pedicelli S, Marini R, Giannone G, Cambiaso P, Cappa M. Congenital primary adrenal insufficiency and selective aldosterone defects presenting as salt-wasting in infancy: a single center 10-year experience. Ital J Pediatr 2016; 42:73. [PMID: 27485500 PMCID: PMC4971679 DOI: 10.1186/s13052-016-0282-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 07/24/2016] [Indexed: 11/25/2022] Open
Abstract
Background Salt-wasting represents a relatively common cause of emergency admission in infants and may result in life-threatening complications. Neonatal kidneys show low glomerular filtration rate and immaturity of the distal nephron leading to reduced ability to concentrate urine. Methods A retrospective chart review was conducted for infants hospitalized in a single Institution from 1st January 2006 to 31st December 2015. The selection criterion was represented by the referral to the Endocrinology Unit for hyponatremia (serum sodium <130 mEq/L) of suspected endocrine origin at admission. Results Fifty-one infants were identified. In nine infants (17.6 %) hyponatremia was related to unrecognized chronic gastrointestinal or renal salt losses or reduced sodium intake. In 10 infants (19.6 %) hyponatremia was related to central nervous system diseases. In 19 patients (37.3 %) the final diagnosis was congenital adrenal hyperplasia (CAH). CAH was related to 21-hydroxylase deficiency in 18 patients, and to 3β-Hydroxysteroid dehydrogenase (3βHSD) deficiency in one patient. Thirteen patients (25.5 %) were affected by different non-CAH salt-wasting forms of adrenal origin. Four familial cases of X-linked adrenal hypoplasia congenita due to NROB1 gene mutation were identified. Two unrelated girls showed aldosterone synthase deficiency due to mutation of the CYP11B2 gene. Two unrelated infants were affected by familial glucocorticoid deficiency due to MC2R gene mutations. One girl showed pseudohypoaldosteronism related to mutations of the SCNN1G gene encoding for the epithelial sodium channel. Transient pseudohypoaldosteronism was identified in two patients with renal malformations. In two infants the genetic aetiology was not identified. Conclusions Emergency management of infants presenting with salt wasting requires correction of water losses and treatment of electrolyte imbalances. Nevertheless, the differential diagnosis may be difficult in emergency settings, and sometimes hospitalized infants presenting with salt-wasting are immediately started on steroid therapy to avoid life-threatening complications, before the correct diagnosis is reached. Physicians involved in the management of infants with salt-wasting of suspected hormonal origin should remember that, whenever practicable, a blood sample for the essential hormonal investigations should be collected before starting steroid therapy, to guide the subsequent diagnostic procedures and in particular to address the analysis of candidate genes.
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Affiliation(s)
- Carla Bizzarri
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Nicole Olivini
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Stefania Pedicelli
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Romana Marini
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Germana Giannone
- Department of Chemistry, Bambino Gesù Children's Hospital, Rome, Italy
| | - Paola Cambiaso
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marco Cappa
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
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Sagar A, Valson A, Bhartiya M. Autoimmune polyglandular syndrome type II: Schimidt's syndrome, a unifying diagnosis in a case presenting with an uncommon combination of multiple endocrine disorders. Indian J Endocrinol Metab 2016; 20:579-580. [PMID: 27366734 PMCID: PMC4911857 DOI: 10.4103/2230-8210.183477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Amitabh Sagar
- Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| | - Arun Valson
- Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| | - Manish Bhartiya
- Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
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18
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De Martino L, Capalbo D, Improda N, Lorello P, Ungaro C, Di Mase R, Cirillo E, Pignata C, Salerno M. Novel Findings into AIRE Genetics and Functioning: Clinical Implications. Front Pediatr 2016; 4:86. [PMID: 27597936 PMCID: PMC4992815 DOI: 10.3389/fped.2016.00086] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/02/2016] [Indexed: 01/22/2023] Open
Abstract
Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED), formerly known as autoimmune polyendocrine syndrome type 1, is a paradigm of a monogenic autoimmune disease caused by mutations of a gene, named autoimmune regulator (AIRE). AIRE acts as a transcription regulator that promotes immunological central tolerance by inducing the ectopic thymic expression of many tissue-specific antigens. Although the syndrome is a monogenic disease, it is characterized by a wide variability of the clinical expression with no significant correlation between genotype and phenotype. Indeed, many aspects regarding the exact role of AIRE and APECED pathogenesis still remain unraveled. In the last decades, several studies in APECED and in its mouse experimental counterpart have revealed new insights on how immune system learns self-tolerance. Moreover, novel interesting findings have extended our understanding of AIRE's function and regulation thus improving our knowledge on the pathogenesis of APECED. In this review, we will summarize recent novelties on molecular mechanisms underlying the development of APECED and their clinical implications.
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Affiliation(s)
- Lucia De Martino
- Pediatric Section, Department of Translational Medical Sciences, Federico II University , Naples , Italy
| | | | - Nicola Improda
- Pediatric Section, Department of Translational Medical Sciences, Federico II University , Naples , Italy
| | - Paola Lorello
- Pediatric Section, Department of Translational Medical Sciences, Federico II University , Naples , Italy
| | - Carla Ungaro
- Department of Pediatrics, Federico II University , Naples , Italy
| | | | - Emilia Cirillo
- Pediatric Section, Department of Translational Medical Sciences, Federico II University , Naples , Italy
| | - Claudio Pignata
- Pediatric Section, Department of Translational Medical Sciences, Federico II University , Naples , Italy
| | - Mariacarolina Salerno
- Pediatric Section, Department of Translational Medical Sciences, Federico II University , Naples , Italy
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