New insights into steroidogenesis in normo- and hyperandrogenic polycystic ovary syndrome patients / Novos aspectos na esteroidogênese em pacientes normo ou hiperandrogênicas com síndrome de ovários policísticos

OBJECTIVE: This study sought to examine corticosteroidogenic enzyme activities in normo- and hyperandrogenic polycystic ovary syndrome (PCOS) patients. SUBJECTS AND METHODS: This cohort study included 81 patients with biochemical hyperandrogenism and 41 patients with normal androgen levels. Enzyme activities were assessed according to the serum steroid product/precursor ratios at baseline and after adrenal stimulation. RESULTS: At baseline, in the delta 4 (Δ4) pathway, hyperandrogenic patients showed greater 17-hydroxylase and 17,20 lyase activities in converting progesterone (P4) into 17-hydroxyprogesterone (17-OHP4) and 17-hydroxypregnenolone (17-OHPE) into androstenedione (A) (p = 0.0005 and p = 0.047, respectively) compared to normoandrogenic patients. In the delta 5 (Δ5) pathway, the 17-hydroxylase and 17,20 lyase enzymes showed similar activities in both groups. Hyperandrogenic patients presented lower 21-hydroxylase, lower 11β-hydroxylase (p = 0.0001), and statistically significant increases in 3β-hydroxysteroid dehydrogenase II (3β-HSDII) activities (p < 0.0001). Following tetracosactrin stimulation, only the 17,20 lyase activity remained up-regulated in the Δ4 pathway (p < 0.0001). CONCLUSION: Hyperandrogenic patients had higher 17,20 lyase activity, both at baseline and after adrenal stimulation. Greater conversion of dehydroepiandrosterone (DHEA) into A with normal conversion of 17-OHPE to 17-OHP4 in hyperandrogenic PCOS patients indicated different levels of 3β-HSDII activity in adrenal cells, and hyperandrogenic patients had lower 11β-hydroxylase and 21-hydroxylase activities.

OBJETIVO: O objetivo deste estudo foi examinar a atividade de enzimas responsáveis pela produção de corticosteroides em pacientes normo e hiperandrogênicas com síndrome de ovários policísticos (SOP). SUJEITOS E MÉTODOS: A coorte estudada incluiu 81 pacientes com hiperandrogenismo bioquímico e 41 pacientes com níveis normais de androgênio. A atividade enzimática foi avaliada de acordo com as proporções de produto/precursor do esteroide sérico, no momento inicial do estudo e depois de estimulação adrenal. RESULTADOS: No momento inicial, na via delta 4 (Δ4), as pacientes hiperandrogênicas mostraram maior atividade da 17-hidroxilase e 17,20 liase na conversão da progesterona (P4) em 17-hidroxiprogesterona (17-OHP4) e na conversão da 17-hidroxipregnenolona (17-OHPE) em androstenediona (A) (p = 0,0005 e p = 0,047, respectivamente) em comparação com pacientes normoandrogênicas. Na via delta 5 (Δ5), a 17-hidroxilase e a 17,20 liase mostraram atividades similares nos dois grupos. As pacientes hiperandrogênicas mostraram menor atividade da 21-hidroxilase, menor atividade da 11β-hidroxilase (p = 0,0001) e aumento estatisticamente significativo na atividade da 3β-hidroxiesteroide desidrogenase II (3β-HSDII) (p < 0.0001). Após a estimulação com tetracosactrin, apenas a atividade da 17,20 liase permaneceu regulada para cima na via Δ4 (p < 0.0001). CONCLUSÃO: As pacientes hiperandrogênicas apresentaram atividade mais alta da 17,20 liase, tanto no momento inicial quanto depois da estimulação adrenal. Maior conversão da desidroepiandrosterona (DHEA) em A com conversão normal da 17-OHPE em 17-OHP4 em pacientes hiperandrogênicas com SOP indica níveis diferentes de atividade da 3β-HSDII em células da adrenal, e pacientes hiperandrogênicas apresentaram menores atividades da 11β-hidroxilase e da 21-hidroxilase.

Pharmacogenetics of glucocorticoid replacement could optimize the treatment of congenital adrenal hyperplasia due to 21-hydroxylase deficiency

INTRODUCTION: 21-hydroxylase deficiency is an autosomal recessive disorder that causes glucocorticoid deficiency and increased androgen production. Treatment is based on glucocorticoid replacement; however, interindividual variability in the glucocorticoid dose required to achieve adequate hormonal control has been observed. OBJECTIVE: The present study aimed to evaluate the association between polymorphic variants involved inglucocorticoid action and/or metabolism and the mean daily glucocorticoid dose in 21-hydroxylase deficiency patients. METHODS: We evaluated 53 patients with classical forms of 21-hydroxylase deficiency who were receiving cortisone acetate. All patients were between four and six years of age and had normal androgen levels. RESULTS: The P450 oxidoreductase A503V, HSD11B1 rs12086634, and CYP3A7*1C variants were found in 19 percent, 11.3 percent and 3.8 percent of the patients, respectively. The mean ± SD glucocorticoid dose in patients with the CYP3A7*1C and wild-type alleles was 13.9 ± 0.8 and 19.5 ± 3.2 mg/m²/d, respectively. We did not identify an association between the P450 oxidoreductase or HSD11B1 allelic variants and the mean glucocorticoid dose. CONCLUSION: Patients carrying the CYP3A7*1C variant required a significantly lower mean glucocorticoid dose. Indeed, the CYP3A7*1C allele accounted for 20 percent of the variability in the cortisone acetate dose. The analysis of genes involved in glucocorticoid metabolism may be useful in the optimization of treatment of 21-hydroxylase deficiency.

Utilidad del estudio molecular de CYP21A2 en el manejo prenatal de hiperplasia suprarrenal congénita: detección de dos nuevas mutaciones en Chile / Molecular study of CYP21A2 gene for prenatal diagnosis of congenital adrenal hyperplasia: Report of a family

Prenatal treatment of pregnancies at risk of congenital adrenal hyperplasia (CAH) may prevent ambiguous genitalia in female fetuses. We present the prenatal treatment performed in an extended family with two mutations. The proband, a boy with CAH-salt losing form, and his relatives were studied. The proband's paternal uncles/aunts were married to the maternal aunts/uncles, respectively. The relatives had normal basal and stimulated 170HProgesterone levels, which did not clarify their carrier status. The CYP21A2 gene was sequenced. The proband and the paternal relatives harbored a Q318X, R483W mutation in one alíele. The maternal relatives and the proband exhibited an R483 frameshift mutation. Early dexametasone treatment was given during two pregnancies and stopped when male gender was confirmed by early ultrasonography Both newborns were healthy and had normal 170HProgesterone levels. This family had three mutations which abolish the 21-hydroxilase activity. Two mutations were detected in codon 483 of CYP21A2 gene, exon 10, which have not been reported previously in Latin-America. The molecular study performed in this family allowed us to give an appropriate genetic counseling and prenatal treatment.

Congenital adrenal hyperplasia clinical: characteristics and genotype in newborn, childhood and adolescence / Hiperplasia suprarrenal congenital: características clínicas, seguimiento y genotipo en la etapa perinatal, la niñez y la adolescencia

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a disorder which can adopt three clinical expressions: two classical forms –salt-wasting (SW), with residual enzymatic activity (EA) < 1% and simple virilizing (SV), with EA 1-2%– and a mild late onset or nonclassical (NC) form, with EA 10-60%. Our objective is to describe clinical characteristics, growth, and bone mass in a group of patients affected by 21-hydroxylase deficiency. Besides, molecular genetics studies were performed in patients, and also when available in their parents and siblings. Nine patients with neonatal diagnosis and 8 with pre or postpubertal diagnosis were studied. Analyses of 10-point mutations in the CYP21A2 gene were performed. We found that all the patients with the classical expression, except one with a de novo mutation R356W in one allele, were fully genotyped with predictive < 2% EA mutations. Signs of hyperandrogenism were present in 5/6 NC patients; one was diagnosed by searching for mutations in asymptomatic siblings. All the NC patients were compound heterozygotes carrying V281L mutation in one allele and a predictive low EA in the other, except for one not yet determined. In patients with neonatal diagnosis, mean height was low at one year of age, though it showed a significant increase before the onset of puberty. We conclude that neonatal diagnosis of classical CAH allows an adequate follow up enhancing growth. Molecular analyses of all members of an affected family may disclose asymptomatic patients. The presence of de novo mutations, as well as, the presence of mutations with low predicted EA in NC patients reinforces the importance of genotyping for appropriate genetic counseling. In fully genotyped NC patients, the lowest value of ACTH-stimulated 17OHP was 14 ng/ml. Lower cut-off values might overestimate the diagnosis of the NC form.

La hiperplasia suprarrenal congénita por déficit de 21-hidroxilasa presenta tres formas clínicas: dos clásicas, perdedora de sal, con actividad enzimática (AE) < 1% y virilizante simple, con AE 1-2% y una no clásica, con AE 10-60%. Nuestro objetivo es describir las características clínicas y el genotipo de un grupo de pacientes con hiperplasia suprarrenal congénita; este último también sedeterminó en todos los miembros de la familia. Se estudiaron 9 pacientes diagnosticados en la etapa perinatal y 8 durante la etapa pre y postpuberal. Se analizaron diez mutaciones en el gen CYP21A2 y se evaluó crecimiento y densidad mineral ósea. Once pacientes presentaron la forma clásica: 9 con diagnóstico perinatal y 2 diagnosticados más tardíamente, uno de ellos con agrandamiento testicular por restos adrenales. Todos los pacientes, salvo 1 con una mutación de novo R356W en un alelo, presentaron ambos alelos mutados con un genotipo que predice AE < 2%. Seis pacientes presentaron la forma no clásica, todos con signos clínicos de hiperandrogenismo salvo un familiar asintomático que se diagnosticó por el estudio molecular. Todos, a excepción de uno con un alelo aún no determinado, presentaron la mutación V281L acompañada de otra que predice AE < 2%. Durante la evolución de los pacientes de diagnóstico perinatal se observó talla baja al año con recuperación de la misma en la etapa prepuberal. La densidad mineral ósea fue normal. Podemos concluir que el diagnóstico en la etapa perinatal en pacientes con la forma clásica posibilita un mejor seguimiento y crecimiento. La genotipificación de todos los miembros de una familia permite el diagnóstico de formas asintomáticas. La presencia de mutaciones de novo y de un alelo con una mutación que predice baja AE en los pacientes con forma no clásica, refuerza la importancia de la genotipificación para un adecuado asesoramiento genético.

Causas raras de pseudo-hermafroditismo feminino: quando suspeitar? / Rare forms of female pseudohermaphroditism: when to investigate?

Neste artigo discutiremos as causas raras de pseudo-hermafroditismo feminino. Hiperplasia congênita adrenal é a causa mais comum da ambigüidade da genitalia externa no nascimento, em fetos 46,XX, devido principalmente à forma clássica de deficiência de 21-hidroxilase. São apresentadas aqui as deficiências de 11beta-hidroxilase e de 3beta-hidroxiesteroide desidrogenase, além da resistência familial aos glicocorticóides, caracterizada pela secreção aumentada de cortisol sem evidência clínica de hipercortisolismo, mas com manifestations de excesso de andrógenos e de mineralocorticóides, decorrente de mutações no gene do receptor do glucocorticóide. Também são discutidas a deficiência de aromatase placentária, caracterizada por masculinização do feto feminino, acompanhada de virilização materna durante a gestação, e deve ser considerada na ausência da hiperplasia adrenal fetal e de tumores maternos produtores de andrógenos e a deficiência da P450-oxidorredutase, além das causas maternas e de quadros dismórficos complexos que levam ao pseudo-hermafroditismo feminino. A investigação requer a análise do cariótipo, dosagens séricas iniciais de 17OH progesterona, 11 desoxicortisol, 17-pregnenolone e andrógenos para avaliar o diagnóstico das diferentes causas de hiperplasia adrenal congênita. Após este diagnóstico ser afastado, dados clínicos e laboratoriais devem ser coletados para afastar as causas ainda mais raras de pseudo-hermafroditismo feminino.

Congenital adrenal hyperplasia

Congenital adrenal hyperplasia [CAH] is an autosomal recessive disorder caused by any of the enzymatic steps requied to synthesize adrenal hormones. Depending on the enzymatic step that is deficient, there may be clinical and laboratory finding. The aim was to evaluate the epidemiology and clinical finding of CAH. The clinical and laboratory characteristics of 68 patients with CAH who were managed in the pediatric Endocrinology unit of Imam Reza Hospital during 7 years were recorded in this study; the clinical and epidemiological characteristics of congenital adrenal hyperplasia were evaluated in 68 patients admitted Imam Reza Hospital in Mashed, also one patient has been followed in endocrine and metabolism pediatric clinic in this time, during 6 years retrospectively and I year prospectively. Parental consanguinity rate among families of patients was higher than the general population in Mashad [73.8% vs 30%]. In 44.6% of patients the history of disease were positive in sibling. 52.2% of patients were males and 47.8% females. 21- Hydroxylase deficiency was present in 60 patients [88.2%], salt - losing form in 40 [66.7%] and simple virilizing form in 20 [33.3%] of them. 11- beta hydroxylase deficiency was present is [10.3%]. Also one case of 3- beta OHSD was reported. The median chronological age at diagnsis in sall- losing form were 75 and 85 days in boys and girls; in simple virilizing form were 46 and 43 months in boys and girls. 14 of girls were considered to be male before diagnosis was established. This study underscores the necessity for prospective neonatal screening, so that the benefits of early diagnosis and treatment can be realized. In addition the incidence of CAH is expected to be high due to a high rate of consanguinity in our population, here genetic counseling before marriage is beneficial in our population

Congenital adrenal hyperplasia: biochemical and molecular perspectives.

Congenital adrenal hyperplasia is a disorder occurring in both sexes and is the commonest cause of ambiguous genitalia. It is a group of autosomal recessive disorders in which, on the basis of an enzyme defect the bulk of steroid hormone production by adrenal cortex shifts from corticosteroids to androgens. Autosomal recessive mutations in the CYP21, CYP17, CYP11B1 and 3betaHSD genes that encode steroidogenic enzymes, in addition to mutations in the gene encoding the intracellular cholesterol transport protein steroidogenic acute regulatory protein StAR can cause CAH. Each of the defects causes different biochemical consequences and clinical features. Deficiencies in 21 hydroxylase (21-OH) and 11beta-Hydroxylase (11beta-OH) are the two most frequent causes of CAH. All the biochemical defects impair cortisol secretion, resulting into compensatory hypersecretion of ACTH and consequent hyperplasia of the adrenal cortex. Research in recent years has clarified clinical, biochemical and genetic problems in diagnosis and treatment of the disorders. Expanding knowledge of the gene mutations associated with each of these disorders is providing valuable diagnostic tools in addition to the biochemical profile and phenotype. Genotyping is useful in selecting instances to provide genetic counseling and to clarify ambiguous cases.

Aspectos genéticos e dúvidas diagnósticas da deficiência da 3 beta-hidroxiesteróide desidrogenase: atualizaçäo / Genetic and diagnostic aspects on 3 beta-hidroxisteroid dehidrogenase defficiency: an update

Nos últimos 10 anos, muito tem-se publicado sobre a diminuiçao da atividade da 3 beta-hidroxiesteróide desidrogenase (3 beta-HSD) por ocasiao da infância, menarca ou mesmo após, determinando por um lado hiperplasia supra-renal congênita e na área ginecológica síndrome dos ovários policísticos devido a instalaçao de um meio androgênico coadjuvante do desvio da funçao ovulatória. Tida como a deficiência enzimática mais freqüente na forma de início tardio das hiperplasias supra-renais, seu diagnóstico era feito através apenas de estudos hormonais em que se comparavam os precursores delta 5 aos delta 4 da esteroidogênese. Tais dados, aceitos como universais, começaram a ser questionados a partir das descobertas recentes da localizaçao dos genes que codificam a atividade enzimática da 3 beta-HSD. Esta revisao procura mostrar os avanços na conduçao diagnóstica desta patologia a partir das últimas publicaçoes sobre o tema. Questiona-se por fim a existência da forma tardia desta enzimopatia.