Can Boys Have Turner Syndrome? More than a Question of Semantics.

Individuals with 45,X mosaicism with Y chromosome material raised as boys are not diagnosed with Turner syndrome, a label restricted to phenotypic females. We sought to determine if boys with 45,X mosaicism had features consistent with Turner syndrome. Twenty-two patients (14 girls, 8 boys) seen in our Differences of Sex Development (DSD) clinic were identified for review. Standardized height (z-scores) by sex of rearing and results of cardiology, renal, audiology, thyroid, and celiac screenings were recorded. All subjects had heights below the mean for sex. Z-scores were not significantly different between boys and girls (p = 0.185). There were no significant differences in the incidence of cardiac anomalies between boys and girls (p = 0.08). Girls were more likely to have additional screenings (p = 0.042), but there were no significant differences in the number of positive screenings between boys and girls (p = 0.332). Patients with 45,X mosaicism raised as boys appear to have features similar to patients with the same karyotype raised as girls. Routine screening of boys following the Turner Syndrome Clinical Practice Guidelines may allow early recognition of comorbidities. Additionally, obtaining karyotypes on boys with short stature or other features of Turner syndrome may identify unrecognized cases of 45,X mosaicism.

Attenuation of Autoimmune Phenomena in a Patient with Autoimmune Polyglandular Syndrome Type 1.

Autoimmune polyglandular syndrome type 1 (APS1) is a progressive life-threatening illness with no known cure. Current treatments involve replacement of the hormone deficiencies that result from autoimmune destruction of multiple endocrine organs. We report on a girl whose disease was progressing rapidly until she began on immunosuppressive agents. A healthy 6-year-old girl with no remarkable medical history presented with new onset hypocalcemic seizures and primary hypoparathyroidism. Howell-Jolly bodies consistent with autoimmune hyposplenism were also noted. Genetic testing revealed compound heterozygosity for 2 disease-associated variants in the autoimmune regulator (AIRE) gene. She later developed elevated liver enzymes, primary adrenal insufficiency, and alopecia totalis. Serologic testing revealed antibodies to 21-hydroxylase, intrinsic factor, and smooth muscle. Hydrocortisone was initiated for adrenal insufficiency. Shortly afterwards, her liver enzymes normalized, and her smooth muscle antibody levels began to decline. Serologic testing performed at age 11 revealed seropositivity for glutamic acid decarboxylase (GAD) antibodies, antinuclear antibodies, and Sjögren syndrome A (SSA) antibodies. At age 12, she was given 2 doses of rituximab. Hair loss rapidly progressed to alopecia totalis and then to alopecia universalis, at which time oral methotrexate treatment was initiated. For the past 7 years while on glucocorticoid and methotrexate treatment, our patient has displayed normalization of 2 antibodies, a lack of progression to additional autoimmune diseases, and experienced reversal of alopecia universalis.

Oxandrolone Use in Trans-Masculine Youth Appears to Increase Adult Height: Preliminary Evidence.

Purpose: Early use of oxandrolone and gonadotropin-releasing hormone analogs has been shown to increase adult height in patients at risk for short stature, but use in trans-masculine (TM) youth to augment height has not been explored. The purpose of this study was to identify the impact of oxandrolone on adult height in TM youth. Methods: This was a single-center, retrospective chart review of TM patients seen between 2013 and 2018. Hormone regimens, heights, mid-parental height, and bone ages were recorded. We examined correlations between adult height and age at the initiation of treatment or with the age of referral (in untreated patients). Results: Of TM patients, 154 had achieved adult height, including 34 who received oxandrolone, 42 who reached adult height before starting gender-affirming hormone therapy (GAHT), and 14 who received no treatment. Adult height correlated inversely with age at hormone initiation in oxandrolone-treated patients only (p = 0.001). Each earlier year of treatment yielded a 2.3 cm increase in adult height. Those who started oxandrolone younger than the median age achieved an adult height of 169.6 ± 6.4 cm compared to 162.1 ± 6.0 cm in those starting later than the median age (p < 0.001), 164.6 ± 4.8 cm in those receiving no treatment (p = 0.02), and 163.9 ± 6.5 cm in those receiving all other regimens (p < 0.001). Conclusions: Early use of oxandrolone may augment adult height in TM youth. Height discussions should be part of comprehensive GAHT counseling.

High Molecular Diagnosis Rate in Undermasculinized Males with Differences in Sex Development Using a Stepwise Approach.

Differences of sex development (DSDs) are a constellation of conditions that result in genital ambiguity or complete sex reversal. Although determining the underlying genetic variants can affect clinical management, fewer than half of undermasculinized males ever receive molecular diagnoses. Next-generation sequencing (NGS) technology has improved diagnostic capabilities in several other diseases, and a few small studies suggest that it may improve molecular diagnostic capabilities in DSDs. However, the overall diagnostic rate that can be achieved with NGS for larger groups of patients with DSDs remains unknown. In this study, we aimed to implement a tiered approach to genetic testing in undermasculinized males seen in an interdisciplinary DSD clinic to increase the molecular diagnosis rate in this group. We determined the diagnosis rate in patients undergoing all clinically available testing. Patients underwent a stepwise approach to testing beginning with a karyotype and progressing through individual gene testing, microarray, panel testing, and then to whole-exome sequencing (WES) if no molecular cause was found. Deletion/duplication studies were also done if deletions were suspected. Sixty undermasculinized male participants were seen in an interdisciplinary DSD clinic from 2008 to 2016. Overall, 37/60 (62%) of patients with Y chromosomes and 46% of those who were 46XY received molecular diagnoses. Of the 46,XY patients who underwent all available genetic testing, 18/28 (64%) achieved molecular diagnoses. This study suggests that the addition of WES testing can result in a higher rate of molecular diagnoses compared to genetic panel testing.

Evidence for alterations in stimulatory G proteins and oxytocin levels in children with autism.

The neurotransmitter oxytocin plays an important role in social affiliation. Low oxytocin levels and defects in the oxytocin receptor have been reported in childhood autism. However, little is known about oxytocin's post-receptor signaling pathways in autism. Oxytocin signals via stimulatory and inhibitory G proteins. c-fos mRNA expression has been used as a marker of OT signaling as well as of G protein signaling. Herein, we hypothesized that oxytocin and its signaling pathways would be altered in children with autism. We measured plasma oxytocin levels by ELISA, G-protein and c-fos mRNA by PCR, and G proteins by immunoblot in cultured peripheral blood mononuclear cells (PBMCs) in children with autism and in age-matched controls. Males with autism displayed elevated oxytocin levels compared to controls (p<0.05). Children with autism displayed significantly higher mRNA for stimulatory G proteins compared to controls (p<0.05). Oxytocin levels correlated strongly positively with c-fos mRNA levels, but only in control participants (p<0.01). Oxytocin, G-protein, and c-fos mRNA levels correlated inversely with measures of social and emotional behaviors, but only in control participants. These data suggest that children with autism may exhibit a dysregulation in oxytocin and/or its signaling pathways.

A Newborn with Genital Ambiguity, 45,X/46,XY Mosaicism, a Jumping Chromosome Y, and Congenital Adrenal Hyperplasia.

Disorders of sex development (DSD), formerly termed "intersex" conditions, arise from numerous causes. CAH secondary to 21-hydroxylase deficiency is the most common cause of DSD. Sex chromosome disorders, including sex chromosome mosaicism, are the second most common cause of DSD. We discuss a medically complex neonate with DSD presenting with ambiguous genitalia. Hormone levels suggested 21-hydroxylase deficiency. Molecular analysis revealed compound heterozygous mutations in the 21-hydroxylase gene (CYP21A2), confirming the diagnosis of CAH. Chromosome analysis revealed sex chromosome mosaicism with three cell lines: 45,X[8]/45,X,tas(Y;16)(p11.32;p13.3)[8]/45,X,t(Y;8)(p11.32;p23.3)[4] with the Y chromosome in telomere association with chromosomes 8p and 16p in different cell lines, a "jumping translocation." Histologically, the right gonad had irregular, distended seminiferous tubules with hyperplastic germ cells contiguous with ovarian stroma and primordial follicles. The left gonad had scant ovarian stroma and embryonic remnants. Chromosome analyses showed mosaicism in both gonads: 45,X[17]/45,X,tas(Y;8)(p11.32;p23.3)[3]. This is the first case of coexisting CAH and 45,X/46,XY mosaicism reported in the English literature and the third case of a constitutional chromosome Y "jumping translocation." Our report documents the medical and genetic complexity of children such as this one with ambiguous genitalia and discusses the need for a multidisciplinary team approach.

Allergic manifestations and cutaneous histamine responses in patients with McCune Albright syndrome.

BACKGROUND: McCune Albright syndrome (MAS) is a rare disorder characterized by precocious puberty, café-au-lait spots, and fibrous dysplasia. Its cause is an activating mutation in the GNAS gene, encoding a subunit of the stimulatory G protein, Gsalpha (Gsα). The action of any mediator that signals via Gsα and cyclic AMP can be up regulated in MAS. We had observed gastritis, gastroesophageal reflux, and anaphylaxis in McCune Albright patients. OBJECTIVE: As histamine is known to signal via histamine 1 (H1) and histamine 2 (H2) receptors, which couple with stimulatory G proteins, we attempted to mechanistically link histamine responsiveness to the activating GNAS mutation. We hypothesized that responsiveness to histamine skin testing would differ between MAS patients and healthy controls. PATIENTS AND METHODS: After obtaining informed consent, we performed a systematic review of histamine responsiveness and allergic manifestations in 11 MAS patients and 11 sex-matched, Tanner-stage matched controls. We performed skin prick testing, quantifying the orthogonal diameters of wheals and erythema. We also quantitated G protein mRNA expression. RESULTS: The peak wheal and flare responses to histamine were significantly higher in MAS patients compared to controls. CONCLUSIONS: This study suggests that MAS patients may be at risk for exaggerated histamine responsiveness compared to unaffected controls.

Adrenal hypoplasia congenita presenting as congenital adrenal hyperplasia.

We report on a patient with genetically confirmed adrenal hypoplasia congenita (AHC) whose presentation and laboratory abnormalities were consistent with the more common condition, congenital adrenal hyperplasia (CAH). The patient presented with failure to thrive and salt wasting. General appearance showed marked hyperpigmentation and normal male genitalia. He displayed mildly elevated 17-hydroxyprogesterone and markedly elevated 11-deoxycortisol levels at baseline and with ACTH stimulation testing. Results were consistent with 11 ß -hydroxylase deficiency. He required glucocorticoids and high doses of mineralocorticoids. The marked elevation in 11-deoxycortisol directed our clinical reasoning away from a hypoplastic condition and towards a hyperplasic adrenal condition. Sequencing of the DAX1 gene (named for dosage-sensitive sex reversal (DSS) locus and the AHC locus on the X chromosome) revealed a missense mutation. A review of the literature revealed that elevated 11-deoxycortisol levels have been noted in kindreds with DAX1 mutations, but only when measured very early in life. A mouse model has recently been described that displays elevated 11-deoxycorticosterone levels and evidence for hyperplasia of the zona glomerulosa of the adrenal gland. We conclude that DAX1 testing may be considered in patients with laboratory evidence of 11 ß -hydroxylase deficiency, especially in those with severe salt wasting.

The effect of letrozole on bone age progression, predicted adult height, and adrenal gland function.

A common problem in pediatric endocrinology is limited growth potential resulting from advancing skeletal maturation. We determined the efficacy of letrozole, an aromatase inhibitor, on delaying bone age advancement in adolescent males with limited growth potential. Twenty-four patients met the study inclusion criteria. Six patients treated with androgen were analyzed separately. Low-dose ACTH stimulation tests were performed to ascertain the effect of letrozole on adrenal gland function. In patients not on androgen, bone age progression decelerated from 1.51+/-0.57 (deltabone age/deltachronological age) before treatment to 0.68+/-0.66 on therapy (mean duration 12.4 months; p <0.0005). Predicted adult height standard deviation scores (SDS) increased from -1.41+/-0.54 to -0.64+/-0.65 on treatment (p <0.0005). Similar results were noted in androgen-treated patients. Approximately one-fourth of patients displayed subnormal responsiveness to ACTH. In summary: 1) letrozole decelerates skeletal maturation, resulting in significant increases in predicted adult height, and 2) letrozole causes mild adrenal suppression.

Use of aromatase inhibitors in children with short stature.

Estrogen has been shown to have an important role in skeletal maturation in both males and females. The use of aromatase inhibitors may provide a means to delay skeletal maturation and increase final height in children with short stature. These medications have been used primarily in women with breast carcinoma and also in children with autonomous estrogen production, such as patients with McCune-Albright Syndrome. Several studies have evaluated the safety and metabolic effects in adults. A few studies in children have evaluated the efficacy and safety of these medications. These studies demonstrate a beneficial effect on bone age advancement and predicted adult height. Other studies have evaluated the effects on bone mineral density, lipid metabolism and adrenal function in children. This review summarizes the studies in the pediatric population and some of the metabolic effects in adults.

Modulation of diabetes with gonadotropin-releasing hormone antagonists in the nonobese mouse model of autoimmune diabetes.

The nonobese mouse model of autoimmune diabetes (NOD mouse) exhibits a strain-dependent preponderance of disease in females. Castration of male NOD mice leads to an increased incidence of diabetes, suggesting that testosterone directly modulates the expression of diabetes in the NOD mouse. However, castration also modulates hypothalamic and pituitary hormone production via removal of the negative feedback effects of testosterone. One hypothalamic hormone with immunomodulatory properties whose expression is increased by castration is GnRH. To test whether the increased incidence of diabetes in castrated male NOD mice is related to an increase in GnRH activity, we treated castrated male NOD mice with Antide, a GnRH receptor antagonist, to determine the effect on the incidence and timing of onset of diabetes. The prevalence of diabetes at 40 wk of age in male NOD mice was 50% in sham-operated mice, compared with an 83% prevalence in castrated males. Antide administration prevented the increased incidence of diabetes in the castrated male mice. Antide reduced total serum IgG levels, IL-6 cytokine expression in cultured splenocytes, and the lymphocytic infiltration of islets. GnRH administration exerted reciprocal effects, leading to earlier timing of onset of diabetes and increases in serum total IgG levels. We conclude that GnRH modulates the expression of diabetes in the NOD mouse independently of gonadal steroids.

Immunomodulatory actions of gonadal steroids may be mediated by gonadotropin-releasing hormone.

Estrogens are considered to be immunostimulatory, whereas androgens are considered to be immunosuppressive. We hypothesized that the divergent actions of gonadal steroids on the immune system may be mediated indirectly, via their potent divergent feedback effects on the hypothalamic hormone GnRH, which is itself immunostimulatory. We used the GnRH-deficient HPG/Bm mouse in an effort to disentangle the effects of gonadal steroids from the effects of GnRH. We randomized GnRH-deficient mice and their GnRH-sufficient littermates to receive androgens, estrogens, or GnRH. We subsequently measured B and T cell proliferative responses to mitogen and serum IgG levels. We demonstrate that estrogens exert stimulatory effects on B cell proliferation and serum IgG levels in the presence of GnRH but not in the absence of GnRH. Testosterone exerts suppressive effects on B cell function in the presence of GnRH but not in its absence. Androgens and estrogens exerted divergent actions on T cell function irrespective of the presence and absence of GnRH, although responses were markedly attenuated in GnRH-deficient mice. Our data suggest that the immunostimulatory effects of estrogen and the immunosuppressive effects of androgens on B cell function may be mediated indirectly via GnRH.

Gender differences and hormonal modulation of G proteins Galpha(q/11) expression in lymphoid organs.

Androgens and estrogens exert potent divergent feedback effects on gonadotropin-releasing hormone (GnRH) production at the level of the hypothalamus and GnRH action at the level of the pituitary. Androgens exert generally suppressive effects on GnRH production and action, whereas rising levels of estradiol increase both GnRH release and action. In addition to its known endocrine actions, GnRH possesses immunomodulatory effects. We have previously demonstrated gender differences in immune responsiveness to GnRH that parallel gender differences in endocrine responsiveness: females appear to be more immunologically responsive to GnRH than males. GnRH exerts its actions via the stimulatory G protein Galpha(q) and Galpha(11) (referred to collectively as Galpha(q/11)) as well as via Galpha(s). We have recently demonstrated that the heightened immune responsiveness to GnRH in lupus-prone female mice correlated with increased expression of Galpha(q/11) in lymphoid cells from females compared to males. We hypothesize that the hormonal milieu of females may contribute to increased expression of stimulatory G proteins and to the heightened immune and endocrine responsiveness to GnRH. In this report, we document gender differences in expression of Galpha(q/11) protein in lymphoid organs in non-autoimmune DBA/2 mice. In an effort to address the mechanisms for the gender differences in G-protein expression, we used competitive reverse transcription PCR to quantitate mRNA for stimulatory G proteins in immune cells under various hormonal conditions. We quantitated the expression of Galpha(q/11) mRNA and protein under physiologic hormonal alterations, i.e. throughout the estrous cycle in female mice. We demonstrate that expression of Galpha(q/11) mRNA and protein in lymphoid organs is significantly increased on the afternoon of proestrus compared to metestrus. Additional studies demonstrate that exposure to GnRH or to estrogens significantly increases the expression of Galpha(q/11) mRNA in immune cells. These findings support an active role for hormonal modulation of G proteins in the gender differences in endocrinologic and immunologic responsiveness to GnRH.

Administration of antisense oligonucleotides to Galpha(Q/11) reduces the severity of murine lupus.

Our principle hypothesis is that the hypothalamic hormone, gonadotropin-releasing hormone (GnRH), is an immunostimulatory hormone and plays a pivotal role in the gender differences in immunity and/or autoimmunity. As a general rule, females display heightened immune responses and heightened endocrinological responsiveness to GnRH compared to males. We have previously demonstrated that GnRH receptor antagonists are effective in ameliorating murine lupus and that GnRH receptor agonists exacerbate murine lupus. GnRH exerts its actions via stimulatory G proteins, specifically via Galpha(s) and the homologous G proteins Galpha(q) and Galpha(11) (referred to together as Galpha(q/11)). We have previously demonstrated that females express higher levels of Galpha(q/11) mRNA and protein compared to males. We hypothesized that antisense inhibition of these specific G proteins would lead to a reduction in inflammatory cytokines and to an amelioration of disease in a mouse model of lupus. We randomized gonadectomized female (NZB x NZW) F1 hybrid mice to treatment with antisense oligonucleotides to Galpha(q/11) or to missense oligonucleotides. Administration of antisense oligonucleotides to Galpha(q/11) led to significant reductions in autoantibody levels, serum IgG levels, hematuria, and proteinuria compared to missense oligos. A trend toward prolonged survival was also noted. In vitro co-culture experiments demonstrated that antisense to Galpha(q/11) significantly inhibited IL-6 production compared to control.

Are pubertal changes in girls before age 8 benign?

OBJECTIVE: The Lawson Wilkins Pediatric Endocrine Society recently issued new recommendations for the age at which puberty should be considered precocious, lowering the prevailing standards from 8 years to 7 years for white girls and to 6 years for black girls. The new recommendations were based on a single epidemiologic study that focused on the conditions of premature thelarche and premature adrenarche (both characterized by a single sign of puberty). Although the data were available, the authors did not comment on the low incidence of true precocious puberty (characterized by breast and pubic hair development) in their population. The hypothesis for the present study is that the new recommendations lead to underdiagnosis of endocrine pathology METHODS: Using 29 International Classification of Diseases, Ninth Revision codes for diagnoses known to be associated with precocious puberty, we identified 1570 patient visits to our outpatient pediatric endocrinology clinic of white girls aged 7 to 8 and black girls aged 6 to 8 during a 5-year period RESULTS: Of the 1570 patient visits, 223 unique patients were identified as having been referred for the sole finding of precocious pubertal development. These 223 patients carried no other endocrine diagnoses. Eleven patients (4.9%) were found to have no true breast buds and no terminally differentiated pubic hair. A total of 105 (47.1%) of 223 patients were found to have 2 signs of puberty, consistent with true precocious puberty according to the conventional guidelines of precocity of 8 years in girls. Overall, 12.3% of patients also had diagnoses of other endocrine conditions that included congenital adrenal hyperplasia, McCune-Albright syndrome, growth hormone deficiency, hypothyroidism, hyperinsulinism, pituitary adenoma, and neurofibromatosis. A total of 35.2% of girls with true precocious puberty exhibited bone ages >3 standard deviations above the mean, indicating markedly diminished growth potential CONCLUSIONS: We conclude that signs of puberty in 6- to 8-year-old girls should not be considered normal or benign. Implementation of the new guidelines for the evaluation of puberty will result in failure to identify conditions that respond to early intervention.