Irregular Menstruation-Hirsutism-Infertility: Clinical Management of Non-Classic Congenital Adrenal Hyperplasia / 罕见病研究

A 38-year-old female presented with irregular menstruation and hirsutism that started at age of 16 and diagnosed with polycystic ovary syndrome at age of 29 with elevated testosterone. When treated with ethinestradiol cyproterone tablets, her menstruation returned to normal and androgen levels was not changed. At age of 38 she was referred to the hospital with infertility, a diagnosis of nonclassical 21-hydroxylase deficiency was confirmed using 17-hydroxyprogesterone, dehydroepiandrosterone-sulfate, a cosyntropin-stimulation test and genetic test. This case suggested that nonclassical congenital adrenal hyperplasia should be considered when a patient is presented with oligomenorrhea, hirsutism with hyperandrogenemia and infertility.

Differences in hormonal levels between heterozygous CYP21A2 pathogenic variant carriers, non-carriers, and females with non-classic congenital hyperplasia

ABSTRACT Objective: CYP21A2 mutation heterozygote carriers seem to have an increased risk of hyperandrogenism. However, the clinical relevance of the heterozygote carrier status and the reliability of hormonal testing in discriminating a carrier from a non-carrier are puzzling questions. We aimed to characterize a population of Portuguese females suspected of having non-classic congenital adrenal hyperplasia (NC-CAH) due to clinical and biochemical criteria and who have undergone CYP21A2 molecular analysis. Subjects and methods: Retrospectively, we have analyzed the clinical records of 131 females (32 girls aged 3-9 and 99 adolescents and premenopausal women aged 13-49) who underwent complete CYP21A2 molecular analysis due to suspicion of NC-CAH. We divided included participants into three groups according to the CYP21A2 molecular analysis: NC-CAH females (46), heterozygous carriers (49), and wild type (36). We then compared clinical signs and symptoms as well as biochemical and molecular data between carriers and NC-CAH individuals and between carriers and wild type females. We measured 17OHP by electrochemiluminescence immunoassay. Results: Clinical features were similar between groups. Heterozygous carriers presented higher basal and post-cosyntropin 17-hydroxyprogesterone (17OHP) than wild type individuals (p < 0.05) and lower basal and stimulated 17OHP levels than NC-CAH patients (p < 0.05). We discovered a considerable overlap between 17OHP levels among groups. The most common pathogenic variant we identified was p.Val282Leu. Conclusion: In this population of hyperandrogenic women and children, heterozygous carriers showed higher basal and stimulated 17OHP than non-carriers although normal basal and stimulated 17OHP responses do not exclude heterozygosity for CYP21A2 pathogenic variants. In this study, only the molecular analysis presented good sensitivity in identifying heterozygotes.

17-hydroxyprogesterone levels in blood from the heels of healthy full-term newborns / Niveles de 17 - hidroxiprogesterona en sangre de talón de neonatos a término sanos

Abstract Background and aim: Congenital adrenal hyperplasia is caused by enzymatic abnormalities in the synthesis of adrenal steroids. A pilot study was carried out to measure the values of 17- hydroxyprogesterone (17-OHP) in a sample of healthy full-term newborns; the present study aims to determine if birth weight or gender have differences on 17-OHP. Design: Transversal, descriptive, and prolective study. Methods: We included 81 healthy full-term newborns with normal prenatal controls born between July 18th, 2014, and August 1st, 2015. We took whole blood from heel pricks when the babies were three to five days old. Socioeconomic and clinical data were collected. Non-extracted 17-OHP ELISA was used. Its cut-off point was 20 ng/ml. If results were above cut-off point, babies were recalled for a new measure since transient high 17-hydroxyprogesterone levels are possible until babies are three months of age. Results: Gestational age varied between 37.0 to 41.5 weeks. Non-extracted 17-OHP levels ranged between 2.6 to 29.5 ng/mL (median: 11.5, IQR 7.2 to 15.1). 17-OHP levels variation per birth weight or gender were not found. Conclusions: Expected lesser variation in term newborns may explain these results. Quality issues should be solved before starting a screening program in our population because socioeconomic issues cause most problems in recalling positive screening babies.

Resumen Justificación: la hiperplasia adrenal congénita es una enfermedad autosómica recesiva ocasionada por anormalidades enzimáticas en la síntesis de los esteroides adrenales. Se realizó un estudio para medir los valores de 17- hidroxiprogesterona en una muestra de neonatos a término sanos. El objetivo fue conocer si existían diferencias en el valor de 17-OHP según edad gestacional y sexo. Diseño: estudio transversal, descriptivo y prolectivo. Métodos: se incluyeron 81 neonatos con controles prenatales normales y nacidos entre julio 18 de 2014 y agosto 1 de 2015. Se obtuvieron muestras de sangre del talón cuando los bebés tenían entre tres a cinco días de vida. Se recolectaron datos socioeconómicos y clínicos. Se utilizó un ELISA de 17-OHP no extraída. El punto de corte de la prueba de ELISA de 17-OHP fue 20 ng/mL. Si los resultados estaban por encima del valor de corte, se citaron los bebés para una nueva medición, dado que es posible hallar una hiper 17-hidroxiprogesteronemia hasta los tres meses de edad. Resultados: la edad gestacional varió entre 37 a 41,2 semanas. Los valores de 17-OHP no extraída variaron entre 2,6 a 29,5 ng/mL (mediana 11,5 y RIQ 7,2 - 15,1). Los niveles de 17-OHP no variaron según peso al nacer o sexo. Conclusión: estos resultados se podrían explicar por una menor variación esperada en neonatos a término. Se deben resolver algunos problemas de calidad antes de poder empezar un programa de tamizaje en nuestra población, debido a que causas socioeconómicas generaron dificultad al reevaluar los niños con resultados positivos de tamizaje.

Ten-year evaluation of a Neonatal Screening Program for Congenital Adrenal Hyperplasia / Avaliação de dez anos de um Programa de Triagem Neonatal para Hiperplasia Adrenal Congênita

Objective Evaluate the Neonatal Screening Program (NSP) for congenital adrenal hyperplasia (CAH) of the Department of Health of the State of Santa Catarina (Secretaria de Estado da Saúde de Santa Catarina, SES/SC), and provide information to improve the program. Subjects and methods Descriptive, retrospective study of 748,395 children screened between January 2001 and December 2010. We analyzed the coverage of the NSP-SES/SC prevalence of CAH, child’s age when the first sample for 17-hydroxyprogesterone (17OHP) measurement was collected, levels of 17OHP, mean age at treatment onset and main clinical manifestations. Results The NSP-SES/SC covered 89% of the live newborns in the State. It diagnosed 50 cases of CAH, yielding an incidence of 1:14,967. Mean age at collection of the first sample was 7.3 days and mean level of 17OHP was 152.9 ng/mL. The most frequent manifestations were virilized genitalia with nonpalpable gonads, clitoromegaly and genital hyperpigmentation. In three girls, the genre established at birth was incorrect. The salt-wasting form was present in 74% of the cases. There was no occurrence of shock or death. Mean age at treatment onset in the salt-wasting form was 17.4 days compared with 54.9 days in those without the salt-wasting form of the disease. All children were treated with hydrocortisone, and those with salt-wasting CAH were also treated with fludrocortisone. Conclusions The incidence of CAH was 1 case to 14,967 live newborns. Collection of the first sample occurred outside the recommended time, resulting in delays in treatment onset. .

Objetivo Avaliar o Programa de Triagem Neonatal da Secretaria de Estado da Saúde de Santa Catarina (PTN-SES/SC) em relação à hiperplasia adrenal congênita (HAC) e fornecer subsídios que possibilitem seu aperfeiçoamento. Sujeitos e métodos Estudo descritivo e retrospectivo de 748.395 crianças triadas no período de janeiro de 2001 a dezembro de 2010, sendo analisados a cobertura do PTN-SES/SC, a prevalência da HAC, a idade na coleta da primeira amostra para 17-hidroxiprogesterona (17OHP), os níveis de 17OHP, a idade média de início de tratamento e as principais manifestações clínicas. Resultados A cobertura do PTN-SES/SC foi de 89% dos recém-nascidos vivos no Estado. Foram diagnosticados 50 casos de HAC, com incidência de 1:14.967. A média de idade na coleta da primeira amostra foi de 7,3 dias e a de 17OHP, de 152,9 ng/mL. As manifestações mais frequentes foram genitália virilizada sem gônadas palpáveis, clitoromegalia e hiperpigmentação genital. Em três meninas ocorreu erro no estabelecimento de gênero ao nascimento. A forma perdedora de sal foi encontrada em 74% dos casos. Nenhum caso de choque ou óbito foi verificado. A média de idade no início do tratamento nos perdedores de sal foi de 17,4 dias e nos não perdedores, de 54,9 dias. Todas as crianças foram tratadas com hidrocortisona e, nos casos com a forma perdedora de sal, associou-se fludrocortisona. Conclusões A incidência de HAC foi de 1 caso para 14.967 recém-nascidos vivos. A coleta da primeira amostra ainda ocorreu fora do tempo preconizado, acarretando atraso no início do tratamento. .

Puntos de corte de 17-hidroxiprogesterona en la detección de Hiperplasia Suprarrenal Congénita / Cut offs levels of 17-hydroxyprogesterone in screening of Congenital Adrenal Hyperplasia / Pontos de corte da 17-hidroxiprogesterona na detecção de Hiperplasia Adrenal Congênita

El presente estudio investiga la utilidad de determinar puntos de corte ajustados según la edad gestacional y el peso al nacer de neonatos (2-100 días) en la cuantificación de 17-hidroxiprogesterona en muestras de sangre seca en papel de filtro. Se analizaron los resultados de 6.266 determinaciones realizadas en el marco del Programa Nacional de Fortalecimiento de la Detección Precoz de Enfermedades Congénitas. Los datos se dividieron en cuatro grupos; Grupo 1: recién nacido pretérmino con bajo peso; Grupo 2: recién nacido pretérmino con peso normal; Grupo 3: recién nacido a término con bajo peso y Grupo 4: recién nacido a término con peso normal. Se establecieron puntos de corte diferentes a partir del cálculo del percentilo 99 de la distribución de frecuencias. Basado en este análisis se realizó la comparación de la tasa de resultados falsos positivos que se obtuvieron según el punto de corte establecido por el fabricante y los obtenidos en el estudio. Los nuevos puntos de corte obtenidos fueron: 217,72 nmol/L, 102,14 nmol/L, 61,62 nmol/L y 82,38 nmol/L para los grupos 1, 2, 3 y 4 respectivamente. Se evidenció una tasa total de falsos positivos del 1% con los nuevos puntos de corte, significativamente menor a la tasa del 6,2% obtenida al utilizar el punto de corte del fabricante. Esto puso en evidencia que el uso de puntos de corte adecuadamente establecidos para la población en estudio reduce significativamente las complicaciones derivadas de las repeticiones de análisis y eventualmente la tasa de recitaciones, lo cual es una importante contribución a la Salud Pública.

The present work studies the usefulness of determining adjusted cut-offs for the quantification of 17-hydroxyprogesterone in dried blood samples on filter paper, taking into account the gestational age and weight of the neonates. The results of 6266 determinations made within the framework of the National Program of Strengthening Early Detection of Congenital Disease were analysed. Data were divided into groups, Group 1: early established from the calculation of the 99 percentiles of the frequency distribution. New cutoff points were: 217.72 nmol/L, 102.14 nmol/L, 61.62 nmol/L and 82.38 nmol/L for groups 1, 2, 3 and 4 respectively. It showed a total rate of 1% false positives with the new cut-off points, which was significantly lower than the rate of 6.2% obtained using the manufacturer's cutoff. This revealed that the use of properly established cut-offs for the study of population reduces significantly the complications derived fromn analysis repetitions and eventually the recitation rate, which is an important contribution to Public Health.

O presente estudo investiga a utilidade de determinar pontos de corte estabelecidos conforme a idade gestacional e o peso ao nascer de neonatos (2-100 dias) na quantificação da 17-hidroxiprogesterona em amostras de sangue seco em papel filtro. Foram analisados os resultados de 6.266 determinações feitas no âmbito do Programa Nacional de Fortalecimento da Detecção Precoce de Doenças Congênitas. Os dados foram divididos em quatro grupos; Grupo 1: recém-nascido pré-termo com baixo peso, Grupo 2: recém-nascido pré-termo com peso normal, Grupo 3: recém-nascido a termo com baixo peso e Grupo 4: recém-nascido a termo com peso normal e foram estabelecidos pontos de corte diferentes a partir do cálculo do percentil 99 da distribuição de frequências. Com base nesta análise foi realizada a comparação da taxa de resultados falsos positivos obtidos conforme o ponto de corte estabelecido pelo fabricante e os obtidos no estudo. Os novos pontos de corte obtidos foram: 217,72 nmol/L, 102,14 nmol/L, 61,62 nmol/L e 82,38 nmol/L para os grupos 1, 2, 3 e 4, respectivamente. Tornou-se evidente uma taxa total de 1% de falsos positivos, com os novos pontos de corte significativamente menor do que a taxa de 6,2% obtida utilizando o ponto de corte do fabricante. Isto revelou que o uso de pontos de corte de forma adequada estabelecidos para a população em estudo reduz significativamente as complicações decorrentes das repetições de análises e eventualmente a taxa de repetição de novos encontros, o que é uma importante contribuição para a saúde pública.

A three-year follow-up of congenital adrenal hyperplasia newborn screening / Um acompanhamento de três anos da triagem neonatal para hiperplasia adrenal congênita

OBJECTIVE: congenital adrenal hyperplasia (CAH) newborn screening can prevent neonatal mortality in children with the salt-wasting form of the disease and prevent incorrect gender assignments, which can occur in females. However, the occurrence of false-positive results in preterm or low-birth-weight newborns creates some diagnostic difficulties, with consequent therapeutic implications. This study aimed to report the results of a pilot project for neonatal CAH screening conducted in the state of Minas Gerais, Brazil from 09/2007 to 05/2008 with a three-year follow-up. METHODS: dried blood specimens were collected on filter paper cards three to seven days after birth of all newborns in the period. Samples were analyzed for 17-hydroxyprogesterone using an enzyme-linked immunosorbent assay (ELISA). RESULTS: a total of 159,415 children were screened. The apparent incidence of the classic variant of the disease was 1:9,963, based on initial diagnoses following newborn screening. During the follow-up period, eight of 16 children initially diagnosed with CAH were reclassified as unaffected, resulting in a revised incidence of 1:19,927. The false-positive rate was 0.31%, and the positive predictive value was 2.1%. Sensitivity and specificity were 100% and 99.7%, respectively. CONCLUSIONS: newborn screening is an important public health policy in developing countries such as Brazil, where CAH remains underdiagnosed. It has great potential to identify children with the disease who otherwise cannot be diagnosed earlier. Long-term follow-up and monitoring of all children with positive screening results are crucial to ensure a correct diagnosis and to calculate a reliable incidence ratio of the disease. .

OBJETIVO: a triagem neonatal para hiperplasia adrenal congênita (HAC) pode evitar a morte de recém-nascidos com a forma perdedora de sal e o registro civil incorreto das meninas. Entretanto, a ocorrência de resultados falso-positivos em recém-nascidos pré-termos ou com baixo peso ao nascer gera dificuldades diagnósticas, com consequentes implicações terapêuticas. O objetivo do estudo foi avaliar os resultados do projeto piloto de triagem neonatal para HAC realizado no estado de Minas Gerais, Brasil, de setembro de 2007 a maio de 2008 com acompanhamento de três anos. MÉTODOS: a dosagem da 17-hidroxiprogesterona foi realizada por ensaio imunoenzimático (ELISA), em amostras de sangue seco coletadas em papel-filtro, três a sete dias após o nascimento de todos os recém-nascidos no período. RESULTADOS: foram triadas 159.415 crianças. Observou-se incidência de 1:9.963 para a forma clássica da doença, baseando-se nos diagnósticos iniciais. Durante o período de acompanhamento, 8 de 16 crianças inicialmente diagnosticadas com HAC foram reclassificadas como não afetadas, resultando em uma incidência corrigida de 1:19.927. A taxa de falsos positivos foi de 0,31%, e o valor preditivo positivo foi de 2,1%. A sensibilidade e a especificidade foram 100% e 99,7%, respectivamente. CONCLUSÕES: a triagem neonatal é uma importante política de saúde pública para países em desenvolvimento como o Brasil, onde a HAC continua subdiagnosticada. Ela possui grande potencial para identificar crianças que poderiam não ter a doença reconhecida precocemente. O acompanhamento em longo prazo e o monitoramento de todas as crianças com resultados positivos na triagem são cruciais para confirmação diagnóstica e para o correto cálculo da incidência da doença. .

Evaluación de sensibilidad-especificidad de valores de 170H progesterona sérica, basales y post estímulo con ACTH, en función del análisis molecular del gen CYP21A2 en la deficiencia de 21-hidroxilasa no clásica / Evaluation of sensitivity and specificity of serum 170H progesterone values at baseline and post ACTH stimulation in the function of molecular analysis of the CYP21A2 gene in non-classic 21-hydroxilase deficiency

La forma no clásica, post natal, de la hiperplasia suprarrenal congénita tiene una incidencia de 1 en 1000 en la población general y afecta al 6% de las mujeres hirsutas. En este estudio se estableció la sensibilidad y la especificidad de la respuesta de los niveles séricos de 17-hidroxiprogesterona (17OHP4) al estímulo agudo con ACTH en 203 pacientes de ambos sexos, pre y post puberales, con hiperandrogenismo, en los cuales se analizó si tenían una alteración molecular del gen CYP21A2. Posteriormente al estudio molecular, los pacientes fueron clasificados en tres grupos de acuerdo al genotipo: Gr0, n=61: ningún alelo mutado (no portadores de mutación); Gr1, n=55: un alelo mutado (portadores) y Gr2, n=87: dos alelos mutados (afectados). Por análisis de regresión logística (curvas ROC) se compararon los valores basales del Gr2 vs Gr0 y se obtuvo un valor de 17OHP4 de 7,2 ng/ml con una sensibilidad del 83% y una especificidad del 85%. Se sugiere entonces que en los pacientes con este nivel basal no se debería realizar el test de ACTH, y habría que confirmar el diagnóstico con el estudio molecular. Los niveles 17OHP4 a los 60 minutos post estímulo con ACTH mayores a 20 ng/ml son confirmatorios del diagnóstico con 84% de sensibilidad y 88% de especificidad. No sería necesario entonces realizar estudios moleculares. Un valor de 15,6 ng/ml diferencia Gr2 de Gr0 con una sensibilidad del 89% y una especificidad del 95%. Este es un buen valor predictivo, pero el análisis molecular no debería obviarse en aquellos casos en los que exista una fuerte sospecha clínica. (AU)

The incidence of non classic congenital adrenal hyperplasia is 1:1000 in the general population and it is present in 6% of hirsute women. In this study, the sensitivity and specificity of serum 17-hydroxyprogesterone (17OHP4) response to acute ACTH stimulation was evaluated in 203 prepubertal and pubertal patients of the two sexes with hyperandrogenism, in whom the CYP21A2 gene was analyzed. After molecular analysis patients were divided in 3 groups according to genotype: Gr0, n=61, no mutated allele (no mutation carrier); Gr1, n=55, one mutated allele (carrier); and Gr2, n=81, two mutated alleles (affected patient). Using logistic regression analysis (ROC curves), basal values in Gr2 vs. Gr0 were compared and a cutoff value of 7.2 ng/ml was defined to separate groups, with 83% sensitivity and 85% specificity. It is suggested then that in patients with levels higher than 7,2 no ACTH test is necessary and molecular analysis is required to confirm diagnosis. Serum 17OHP4 values above 20 ng/ml 60 minutes after ACTH are confirmatory of diagnosis, with 84% sensitivity and 88% specificity. No molecular studies should be necessary. A 15.6 ng/ml cutoff value is able to differentiate Gr2 from Gr0, with 89% sensitivity and 95% specificity. It is a good predictive value, but carrying out molecular analysis is only advisable if clinical evidence is strong (AU)

Mechanism of varied responsiveness to ACTH in patients with polycystic ovary syndrome / 中华内分泌代谢杂志

Objective To explore the potential mechanism of adrenal androgen excess in patients with polycystic ovary syndrome (PCOS), ACTH stimulation test was conducted and the polymorphisms in the promoter region of CYP21 A2 gene were screened to verify the variations related to the responsiveness to ACTH stimulation. Methods 30 healthy women and 101 PCOS patients, matched for age, were recruited from Ruijin hospital. Blood biochemical examinations were taken and sex hormone profiles obtained at baseline. 17 hydroxyprogesterone( 17OHP)was measured at 0 and 60 min in an ACTH stimulation test. The -710 bp -1 bp of the promoter region of CYP21A2 was sequenced in 87 PCOS patients and 30 control subjects. Results According to the post-stimulation 17 OHP levels obtained from 30 healthy women,PCOS patients were allocated into one group with high responsiveness to ACTH ( HR-PCOS, n = 21) and the other with normal responsiveness to ACTH ( NR-PCOS, n = 80). Compared with NR-PCOS subjects, HR-PCOS patients had higher testosterone( P<0.05), basal and post-stimulation 17OHP (both P<0.01)and dehydroepiandrosterone sulfate levels (P<0.05 or P<0.01) .whereas serum cortisol and androstenedione levels were not significantly different before and after ACTH stimulation test. The genotypes of locus -535 were well correlated with post-stimulation 17OHP levels (r = 0. 20,P = 0. 03) in PCOS patients and the control subjects. The genotype T/T or allele T was significantly more frequent in subjects with a higher fertile of post-stimulation 17OHP (P<0.05 or P<0. 01). The odds ratio(OR)for higher responsiveness to ACTH in women with allele T at -535 was 3. 69 (95% CI 1. 69-8. 06,P = 0. 000 7). Conclusions The PCOS patients with higher responsiveness to ACTH are characterized by severe hyperandrogenemia and adrenal androgenexcess,suggesting that adrenal androgen excess in some PCOS patients may be due to higher responsiveness to ACTH. The polymorphism of -535C>T in the promoter region of CYP21 A2 may play a role in regulating 21 hydroxylase gene expression and further influencing 17OHP responsiveness to ACTH.

Cutoff Value of 17-Hydroxyprogesterone Screening Test for Congenital Adrenal Hyperplasia According to Birth Weight / 임상검사와정도관리

BACKGROUND: False positive rate of 17-OHP screening test was higher more than other screening tests due to use same cutoff value both term and preterm infants in Korea. The purpose of this study is to set cutoff value of 17-OHP on the basis of birth weight in neonatal screening for congenital adrenal hyperplasia. METHODS: 17-OHP was measured in filter paper blood spots obtained by heel puncture between 3 and 7 days after birth. 17-OHP values were analyzed with respect to birth weight in order to decide the appropriate cutoff values in a neonatal screening for congenital adrenal hyperplasia. RESULTS: The mean concentrations of 17-OHP according to birth weight groups were as follows : 12.6, 7.0, 5.1, 3.7, 3.0, 2.5 ng/mL for birth weight of 1.50 or less, 1.50-1.99, 2.00-2.49, 2.50-2.99, 3.00-3.49, 3.50 kg or more, respectively. The cutoff values for determining the 17-OHP for recall were decided as follows : 55, 35, 18, 11, 8, 8 ng/mL for birth weight of 1.50 or less, 1.50-1.99, 2.00-2.49, 2.50-2.99, 3.00-3.49, 3.50 kg or more, respectively. Application of the new cutoff values according to birth weight dropped the total recall rate from 3.3% to 1.0%. CONCLUSIONS: The cutoff values of 17-OHP on the basis of birth weight should be used in the neonatal screening for congenital adrenal hyperplasia. We believe that the recall rate due to false positive can be reduced using this method in low birth weight infants.

An Analysis of Two-Year Experience in Neonatal Screening / 대한진단검사의학회지

BACKGROUND: This study was undertaken to evaluate whether the currently used cut-offs are appropriate and whether there is a significant relationship between false positive results and post-natal well being in neonatal screening. METHODS: During the period of January 2001 through December 2002 at Samsung Medical Cen-ter, neonatal screening tests for TSH, free thyroxine (FT4), phenylketonuria (PKU), galactosemia and 17-hydroxyprogesterone (17-OHP) were performed in newborns using commercial ELISA kits. We reviewed the recall rates at currently used cut-offs and analyzed the relationship between false positive results and postnatal well-being. RESULTS: We obtained false positive results of 2.42%, 0.86%, 1.5%, 0.95% and 0.97% for TSH, FT4, PKU, galactosemia, and 17-OHP, respectively. Twelve babies out of 5, 918 was diagnosed with hypothyroidism. The false positive results of 17-OHP and FT4 were mostly seen in premature babies. Simultaneous false positive results of 17-OHP and other neonatal screen such as FT4 or galactosemia showed poor prognostic outcome in premature babies (odds ratio 6.08, P=0.0006). CONCLUSIONS: In galactosemia, PKU, and 17-OHP, it would be reasonable to modify the cut-offs to 99.7 percentile after measuring those substances from enough number of healthy neonates. The babies who have been treated with L-thyroxine by the current cut-offs of TSH or FT4 were relatively large in number, thus, prospective follow-up of evaluation of the cut-offs of TSH or FT4 is necessary. Also, a simultaneous positivity of 17-OHP and FT4 or galactosemia could be considered as a poor prognostic factor in postnatal well-being.

Analysis of Blood Spot 17-Hydroxyprogesterone Concentration According to Gestational Age and Birth Weight / 대한임상병리학회지

BACKGROUND: High levels of 17-hydroxyprogesterone (17-OHP) are frequently observed in premature infants without congenital adrenal hyperplasia. The purpose of this study is to set cut-off limits of 17-OHP on the basis of gestational age at birth and birth weight. METHODS: Blood spot 17-OHP concentrations were measured in 1,000 infants on the 3th day of life at Inha University Hospital. An enzyme-linked immunosorbent assay (ELISA) method (ICN Neoscreen ELISA 17-hydroxyprogesterone kit, ICN Pharmaceuticals. Inc., Japan) was used. The values obtained were analyzed with respect to birth weight and gestational age at birth in order to decide the appropriate cut-off limits in a neonatal mass screening for 21-hydroxylase deficiency. RESULTS: In the neonatal mass screening for CAH, the cut-off limits for determining the 17-OHP for recall, were decided as follows: (1) 57.65, 39.88, 33.52 ng/mL for gestational age at birth of 35 weeks or less, 36-37, and 38 weeks or more, respectively, and (2) 54.88, 43.86, 32.92 ng/mL for birth weight of 2.49 or less, 2.50-2.99, 3.00 kg or more, respectively. CONCLUSIONS: The cut-off limits on the basis of gestational age at birth and birth weight should be used in the screening for congenital adrenal hyperplasia. We believe that the false positive rate in premature infants can be reduced using this method.

Be aware of non-classical 21-hydroxylase deficiency and improve its treatment / 中华内分泌代谢杂志

Non-classical 21-hydroxylase deficiency(21OHD)is one of the most frequent autosomal recessive hereditary disease.Non-classical 21OHD is often underdiagnosed or misdiagnosed in patients with hyperandrogenemic symptoms(such as hirsutism,acne),menstrual disorder and infertility because of its moderate symptoms and hormonal abnormalities.However,the long-term healthy risks of non-classical 21OHD,such-as insulin resistance,dyslipidemia and cardiovascular diseases are clearly elevated.Basal and ACTH-stimulated 17- hydroxyprogesterone levels are quite helpful as a screening approach in diagnosis of non-classical 21OHD. Furthermore,non-classical 21OHD can be effectively treated with low-cost,therefore we should pay great attention to the diagnosis and treatment of non-classical 21OHD.

A novel heterozygous complex mutation of CYP21 gene may cause non-classical 21-hydroxylase deficiency / 中华内分泌代谢杂志

Objective To investigate the clinical and genetic characteristics of a case with non-classical 21-hydroxylase deficiency(210HD).Methods Clinical features and laboratory data were obtained from a patient with non-c]assical 21OHD,and the promoter and coding areas of CYP21 gene were sequenced.Results The old female patient presented with hypertension.The laboratory examinations showed that plasma androstenedione, testosterone,progesterone and 17-hydroxy progesterone(17OHP)were increased.CT scan revealed bilateral adrenal nodular enlargement.Furthermore,rapid ACTH stimulation test showed that the plasma 17OHP concentration was further increased up to 68.3?g/L.Sequencing analysis showed a C1187T(R356W) substitution at exon 8 and the C-125T,G-112A,T-109C variations in the promoter of CYP21 gene,which was not previous reported.Conclusion The combined heterozygous mutations,Cl187T at exon 8 and C-125T,G -112A,T-109C in promoter,seem to be associated with non-classical 21OHD phenotype.

Variables Influencing 17-Hydroxyprogesterone Values in Newborn Screening for Congenital Adrenal Hyperplasia

PURPOSE: Congenital adrenal hyperplasia(CAH), which is classified into salt-wasting, simple virilization and non-classic type according to clinical features, is difficult to detect in early stages. Failure to diagnose it in the initial state may lead to life-threatening adrenal crisis, inappropriate male sex assignment in the genetic female, acceleration of skeletal maturation and subsequent short stature. Therefore, we studied the variables increasing the 17-hydroxyprogesterone(OHP) values for more specific and sensitive diagnosis of CAH. METHODS: We classified 3,532 newborns into variable factors; gestational age, birth weight, gender, delivery type, sampling date and stress. Then, we analysed the relationships between 17-OHP values and variable factors. RESULTS: The mean value of 17-OHP was 4.21+/-0.03ng/ml. There were significant differences among the variable factors except gender. The mean value of male was 4.26ng/ml, and that of female was 4.15ng/ml(P=0.10). The mean value of 17-OHP in vaginal delivered newborn was higher than C-section delivered ones(4.71ng/ml, 3.34ng/ml, P=0.0001). It was also higher in low birth weight(P=0.0001), in prematurity(P=0.001), those sampled within 4 days(P=0.0001), stressful condition and ventilator care-assisted(P=0.004). CONCLUSION: 17-OHP value in neonatal screening is influenced by several variables such as vaginal delivery, ventilator management, low birth weight, sampling date and prematurity. If the 17-OHP value is increased, we have to consider the variables influencing the increase in value and follow up with time interval or analysis of genetic mutations.

Variables Influencing 17-Hydroxyprogesterone Values in Newborn Screening for Congenital Adrenal Hyperplasia

PURPOSE: Congenital adrenal hyperplasia(CAH), which is classified into salt-wasting, simple virilization and non-classic type according to clinical features, is difficult to detect in early stages. Failure to diagnose it in the initial state may lead to life-threatening adrenal crisis, inappropriate male sex assignment in the genetic female, acceleration of skeletal maturation and subsequent short stature. Therefore, we studied the variables increasing the 17-hydroxyprogesterone(OHP) values for more specific and sensitive diagnosis of CAH. METHODS: We classified 3,532 newborns into variable factors; gestational age, birth weight, gender, delivery type, sampling date and stress. Then, we analysed the relationships between 17-OHP values and variable factors. RESULTS: The mean value of 17-OHP was 4.21+/-0.03ng/ml. There were significant differences among the variable factors except gender. The mean value of male was 4.26ng/ml, and that of female was 4.15ng/ml(P=0.10). The mean value of 17-OHP in vaginal delivered newborn was higher than C-section delivered ones(4.71ng/ml, 3.34ng/ml, P=0.0001). It was also higher in low birth weight(P=0.0001), in prematurity(P=0.001), those sampled within 4 days(P=0.0001), stressful condition and ventilator care-assisted(P=0.004). CONCLUSION: 17-OHP value in neonatal screening is influenced by several variables such as vaginal delivery, ventilator management, low birth weight, sampling date and prematurity. If the 17-OHP value is increased, we have to consider the variables influencing the increase in value and follow up with time interval or analysis of genetic mutations.

Serum 17-Hydroxyprogesterone Levels in Term and Preterm Infants / 대한소아내분비학회지

PURPOSE:The incidence of congenital adrenal hyperplasia(CAH) is 1/5,000- 1/20,000 births and thus the importance of the neonatal screening test is being emphasized. However, the reference value for the term and preterm infants has not yet been established and false positive values are frequent due the immature hypothalamic-adrenal axis of the preterm infants or the stress-induced adrenal dysfunction. Therefore, we analyzed the 17-hydroxyprogesterone(17-OHP) concentration in terms of gestational age, birth weight, and postnatal state to establish the reference range for the Korean term and preterm infants. METHODS:We analyzed the results of the CAH screening test retrospectively, which was performed on 737 neonates(624 fullterm neonates, 113 premature neonates) born between January 1998 through July 1998 in Inje University College of Medicine Sanggye Paik Hospital. Mean gestational age and birth weight of infants were 38.2+/-2.6 weeks and 3,116+/-674kg respectively. 17-OHP screening test was performed on 4.9+/-3.8days after birth by obtaining blood samples from the heelstick of neonates. 17-OHP concentration was measured by the ELISA kit(ICN Co.) and repeated the procedure if the result was higher than 35ng/ml. RESULTS: 1) 17-OHP concentration of the preterm infants was significantly higher than that of the fullterm infants(19.1+/-12.3ng/ml vs 11.7+/-7.8ng/ml, P=0.001). 17-OHP concentration was inversely proportional to gestational age. 2)17-OHP concentration was inversely proportional to birth weight(r=0.22, P>0.01). 17-OHP concentration according to birth weight was as follows.:below 1,500g was 26.7+/-11.7ng/ml, 1,500 to 2,000g was 18.0+/-13.9ng/ml, 2,001 to 2,500g was 17.9+/-10.5ng/ml, 2,501 to 3,000g was 12.1+/-7.9ng/ml, 3,001 to 3,500g was 11.5+/-8.1ng/ml, above 3,500g was 11.4+/-7.5ng/ml. There was a significant decline in the 17-OHP concentration as the birth weight increased. 3) 17-OHP concentration was gradually decreased as sampling date increased. 4) The gender of the infants did not influence the 17-OHP concentration(male 13.0+/-9.1 vs female 12.7+/-9.0). 5)17-OHP concentration were significantly higher in sick preterm infants than healthy preterm infants. 6)Six cases, whose 17-OHP concentration were greater than 35ng/ml, were all preterm and low birth weight infants. Reexamination after one week showed the value within normal range. No CAH cases were diagnosed in the study. CONCLUSION: 17-OHP concentration was inversely proportional to gestational age and birth weight. Therefore, reference ranges of 17-OHP concentration should be subdivided according to gestational age and birth weight. Further research about perinatal risk factors affecting the 17-OHP concentration will be required.

Cortisol and 17-hydroxyprogesterone in saliva.

Radioimmunoassays of cortisol and 17OHP in saliva may replace the blood and urine measurements. The steroids in saliva obtained from normal subjects showed similar patterns of circadian rhythm, menstrual profiles and the responses to dynamic tests as seen in blood. The concentrations of these two salivary steroids measured here are similar to those previously reported and the advantages of salivary steroid measurements are suggested for routine clinical assessment of adrenocortical function.