Testicular adrenal rest tumors develop independently of long-term disease control: a longitudinal analysis of 50 adult men with congenital adrenal hyperplasia due to classic 21-hydroxylase deficiency.

CONTEXT: Testicular adrenal rest tumors (TARTs) and hypogonadotropic hypogonadism are the two most common causes for male infertility in classic 21-hydroxylase deficiency. Current hypotheses suggest the quality of disease control to be one of the main pathogenic factors for TART development. OBJECTIVE: The aim was to study long-term predictors for TART development in a retrospective longitudinal study. DESIGN: Fifty men with classic 21-hydroxylase deficiency (31 salt wasting, 19 simple virilizing) were investigated. Testicular ultrasound at a median age at investigation of 27 years detected TARTs in 28 of 50 subjects (19 salt wasting, 9 simple virilizing). TART presence was correlated with long-term parameters of disease control during childhood and adolescence obtained from patients' charts: 24-hour urine pregnanetriol, serum 17-hydroxyprogesterone, onset and stage of pubic hair development, testicular growth, and bone age in relation to chronological age. RESULTS: There was no difference in pregnanetriol excretion over lifetime between patients with and without TARTs. Similarly, neither development of pubic hair and testicular volume (Tanner) nor bone age in relation to chronological age differed between the two groups. Furthermore, the two groups had the same body mass index and the same impairment of final height in relation to midparental target height. CONCLUSION: Our longitudinal analysis demonstrates no association between TART presence and parameters of disease control. These data, therefore, argue for other mechanisms more relevant for TART induction including those occurring during fetal development.

Dehydrosteroid measurements in maternal urine or serum for the prenatal diagnosis of Smith-Lemli-Opitz syndrome (SLOS).

In a large multi-center trial involving prenatal screening for Smith-Lemli-Opitz syndrome (SLOS), we evaluated maternal urine and serum steroid analysis as a non-invasive diagnostic alternative to amniotic fluid sterol analysis. Candidate steroid ratios included: 7-dehydropregnanetriol/pregnanetriol (7-PT/PT), 8-dehydropregnanetriol/PT (8-PT/PT), the sum of these two (7 + 8-PT/PT), and dehydroestriol/estriol (DHE3/E3). Results are presented from 19 SLOS pregnancies, and 732 reference pregnancies that were screen positive for SLOS but negative on testing in amniotic fluid. Steroid ratios are expressed as multiples of the 75th centile (MoS), rather than multiples of the median, as most reference measurements were undetectable. All four urine ratios were available in 12 SLOS pregnancies; the median 7-PT/PT MoS was 94, with no overlap between affected and reference pregnancies in the second trimester. The separation between these groups increased by 27% per week. The other three ratios performed similarly in urine, with (7 + 8)-PT/PT ratios being marginally superior, due to fewer high reference outliers. All four steroid ratios in urine were diagnostic for SLOS between 14 and 22 weeks' gestation. In six SLOS pregnancies in which all serum analytes were measured, the median 7-PT/PT MoS was 71, and there was slight overlap in the second trimester. The separation increased by 28% per week. Steroid ratios in serum were less definitive than in urine but might be useful in certain circumstances, at 14 weeks gestation or later. Urine testing performance prior to 14 weeks gestation appears promising, but reference data are sparse.

Dehydro-oestriol and dehydropregnanetriol are candidate analytes for prenatal diagnosis of Smith-Lemli-Opitz syndrome.

Gas chromatographic/mass spectrometric (GC/MS) analysis of maternal urine and serum steroids from 13 pregnancies at 25% risk for Smith-Lemli-Opitz syndrome (SLOS) was undertaken. All patients were between 12 and 31 weeks' gestational age. From dehydrocholesterol/cholesterol ratios determined in amniotic fluid and chorionic villus cells, five patients were shown to carry SLOS affected fetuses and eight patients were negative for the condition. Because it had previously been shown that dehydro-oestriol and dehydropregnanetriol were novel steroids produced in SLOS, these compounds were measured in the serum and urine samples of the 13 mothers. All five urine samples from SLOS affected pregnancies had high levels of both dehydrosteroid metabolites, which were below the detection limit in the non-affected pregnancies. The ratios of dehydro-oestriol/oestriol (DHE(3)/E(3)) were between 0.073 and 1.42 for the affected patients and less than 0.01 for unaffected patients. Corresponding values for dehydropregnanetriol/pregnanetriol (DHPT/PT) were 0.037-1.02 for affected and less than 0.01 for unaffected. In the positive serum sample available for analysis, the DHE(3)/E(3) ratio was 0.20 [unaffected (n=5), <0.014]. It is proposed that the measurement of DHE(3) and DHPT in maternal urine and serum may allow non-invasive antenatal diagnosis of SLOS.

Plasma-sulfated C21-steroids increase during the periovulatory period in female common wolffish and are influenced by temperature during vitellogenesis.

Plasma concentrations of steroids during the periovulatory period were measured in female common wolffish reared at three different temperatures. Steroids were quantified by radioimmunoassay (RIA). Two "broad-spectrum specificity" RIAs-one which detects C21-steroids with a 17,20beta-dihydroxyl configuration (17,20beta-steroids) and the other which detects C21-steroids with a 5beta-reduced, 3alpha-hydroxyl configuration (5beta,3alpha-steroids)-picked up very large amounts of cross-reacting material (1.7 microg ml(-1) in one fish) in the sulfate fraction of plasma from ovulating females. Reverse-phase high-performance liquid chromatography and thin-layer chromatography revealed two major steroids: 5beta-pregnane-3alpha,17,20beta-triol (80%) and 5beta-pregnane-3beta,17,20beta-triol (20%). The sulfated forms of these steroids were elevated 4 to 6 days before and during ovulation, compared with those of females in vitellogenic and postspawning condition, in which concentrations were below 2.0 ng ml(-1). In the three groups of fish held at 4, 8, and 12 degrees C during vitellogenesis, but returned to 4 degrees C just prior to the spawning season, the mean concentrations of sulfated 17,20beta-steroids in ovulating females were 530, 635, and 325 ng ml(-1), respectively. The corresponding concentrations of free 17,20beta-dihydroxy-4-pregnen-3-one (17,20beta-P; the maturation-inducing steroid in many teleosts) were 0.88, 0.86, and 0.57 ng ml(-1), respectively. Only minute amounts of 17,20beta,21-P and its sulfated derivatives were detected. Significantly lower steroid concentrations in the 12 degrees C group indicate that steroid synthesis and/or metabolism during the periovulatory period are influenced by the temperature experienced during vitellogenesis. In male fish, plasma concentrations of both sulfated 17,20beta-steroids and free 17,20beta-P were low (< 2.0 ng ml(-1)) at all times.

Deletion of amino acids Asp487-Ser488-Phe489 in human cytochrome P450c17 causes severe 17 alpha-hydroxylase deficiency.

17 alpha-Hydroxylase deficiency blocks the biosynthesis of cortisol and sex steroids, resulting in mineralocorticoid excess, hypertension, sexual infantilism, and female phenotype in both genetic sexes. The disease is caused by mutations in the gene encoding cytochrome P450c17, which is the single enzyme that mediates both 17 alpha-hydroxylase and 17,20-lyase activities. We report a 14-yr-old patient from Thailand with a classical clinical presentation of this rare disorder. Analysis of her P450c17 gene by polymerase chain reaction amplification and sequencing showed a nine-base deletion, eliminating codons 487-489 (Asp-Ser-Phe) near the carboxy-terminus of P450c17. This deletion creates a BclI site in the mutant DNA, permitting accurate demonstration that the patient was homozygous for this lesion, whereas one parent and two siblings were heterozygous. By use of site-directed mutagenesis, we created a vector that could express this mutated form of P450c17 when transfected into non-steroidogenic COS-1 cells. Such transfected cells produced immunodetectable P450c17 protein, but had no 17 alpha-hydroxylase or 17,20-lyase activity, whereas cells similarly transfected with a vector expressing normal human P450c17 could 17 alpha-hydroxylate either pregnenolone or progesterone and convert 17 alpha-hydroxypregnenolone to dehydroepiandrosterone, showing the presence of both activities. This is the first report of the molecular genetic basis of 17 alpha-hydroxylase deficiency in a Southeast Asian patient.

Levels of 17 alpha,20 alpha-dihydroxy-4-pregnen-3-one, 3 beta,17 alpha,20 alpha-trihydroxy-5 beta-pregnane, and other sex steroids, in blood plasma of male dab, Limanda limanda (marine flatfish) injected with human chorionic gonadotrophin.

In a previous study, plasma sex steroid levels were measured in female dab (Limanda limanda) induced to ovulate by injections of human chorionic gonadotrophin (HCG). In the present study, a similar experiment was carried out on male dabs. In common with female dabs, 17 alpha,20 alpha-dihydroxy-4-pregnen-3-one and 3 beta,17 alpha,20 alpha-trihydroxy-5 beta-pregnane showed the greatest response. Their plasma levels increased, respectively, from 6 +/- 1.6 and 13 +/- 6.2 ng/ml to ca. 62 ng/ml within 36 hr and then decreased. Levels of both steroids remained low in fish injected with saline. There was no statistically significant effect of HCG on plasma testosterone or 11-ketotestosterone concentrations. Initial levels of both hormones were between 10 and 20 ng/ml, and decreased simultaneously in both HCG- and saline-injected fish. Levels of 17 alpha-hydroxy-4-pregnen-3,20-dione, 17 alpha,20 beta-dihydroxy-4-pregnen-3-one, 11-deoxycortisol, and 17 alpha,20 beta, 21-trihydroxy-4-pregnen-3-one were mostly below the detection limits of the assays (0.4 ng/ml). There was no statistically significant effect of HCG on either the total volume of milt collected or the proportion occupied by spermatozoa.

Synthesis of 20 alpha-hydroxylated steroids by ovaries of the dab (Limanda limanda).

Dab (Limanda limanda) ovarian fragments were incubated in vitro with either [4,7-3H]pregnenolone or 17 alpha-hydroxy[1,2,6,7-3H]progesterone to investigate the pattern of steroidogenesis. A major enzyme found in the dab ovary was 20 alpha-hydroxysteroid dehydrogenase. Among the steroids that were tentatively identified in ovarian incubates were 17 alpha,20 alpha-dihydroxy-4-pregnen-3-one (17,20 alpha-P). 17 alpha,20 alpha-dihydroxy-5 beta-pregnan-3-one, 3 beta, 17 alpha,20 alpha-trihydroxy-5 beta-pregnane (3 beta,17,20 alpha-P-5 beta), and 3 alpha,17 alpha,20 alpha-trihydroxy-5 beta-pregnane. The presence of these steroids in plasma of mature female and male dabs was studied by radioimmunoassay. The antiserum was raised against 17,20 alpha-P. The 17,20 alpha-[3H]P label was produced by incubating place milt with 17 alpha-hydroxy [3H]progesterone. The radioimmunoassay was shown to have a high cross-reaction with the 5 beta-reduced analogues of 17,20 alpha-P and was therefore used, in conjunction with thin-layer chromatography, to measure the steroids. High concentrations of both 17,20 alpha-P and 3 beta,17,20 alpha-P-5 beta found in female and male dab plasma. The possible role of these steroids is discussed.

Urinary and serum steroid concentrations in the management of congenital adrenal hyperplasia. Lack of physiologic correlations.

Serum concentrations of 17-hydroxyprogesterone, dehydroepiandrosterone, dehydroepiandrosterone sulfate, progesterone, testosterone, and androstenedione and 24-hour excretion of 17-ketosteroids and pregnanetriol were measured serially in 18 children with congenital adrenal hyperplasia (21-hydroxylase deficiency) during a two-year period. Correlations were sought between results of measurements of these steroids and clinical progress assessed by physical examination and skeletal maturity to determine if measurement of concentration of these substances at a single point in time could be used to gauge the dose of corticosteroids for optimum treatment. We found that these measurements of steroids were generally not useful indicators of optimum control of the disease. Repeated careful clinical examination and assessment of changes in growth velocity and skeletal maturation seem to be the best criteria on which to base dosage of corticosteroids used for therapy.

Plasma adrenocorticotrophic hormone in congenital adrenal hyperplasia. Importance in long-term management.

In a prospective study, assays of plasma adrenocorticotrophic hormone (ACTH) were compared with established criteria to evaluate the determination's usefulness in monitoring the control of congenital adrenal hyperplasia (CAH). In 22 infants and children with 21-hydroxylase deficiency, the plasma ACTH value correctly identified the status of control in 51 of 73 (70%) patient visits. Plasma ACTH concentrations were significantly higher in patients whose conditions were out of control when compared with patients whose conditions were under control, although there was an overlap between the two groups. Plasma ACTH concentrations were significantly higher in patients with sodium-losing CAH than in patients with non-sodium-losing CAH. These findings support the concepts that patients with the sodium-losing condition have a more severe enzyme deficiency and that ACTH stimulation may be affected by sodium balance. Although plasma ACTH determinations are a useful adjunct in the long-term management of CAH, they cannot be relied on as the sole criterion of control.

Gonadal dysfunction in adult men with congenital adrenal hyperplasia.

Two adult males are described with congenital adrenal hyperplasia (21-hydroxylase deficiency). Patient 1 was receiving therapy with cortisone acetate and presented with clinical features of glucocorticoid excess and uncontrolled adrenal androgen activity. It was established that the short-acting steroid which the patient was receiving was cleared so rapidly that endogenous ACTH secretion was not inhibited. Patient 2 presented with enlarged and painful testes in association with poor compliance with corticosteroid therapy. The histologic picture of the testis was compatible with 'Leydig cell hyperplasia'. However, successful response to dexamethasone therapy suggests that the testes harboured an adrenal rest. These observations highlight the need for careful follow-up and treatment of adult male patients with congenital adrenal hyperplasia.

Effect of maternal intrahepatic cholestasis on fetal steroid metabolism.

Estriol, estriol sulfate, progesterone, and 17 neutral steroid sulfates, including estriol precursors and progesterone metabolites, were determined in 27 cord plasma samples collected after pregnancies complicated by intrahepatic cholestasis of the mother. The levels of these steroids were compared with those in the cord plasma of 42 healthy controls. In the cord plasma, the steroid profile after pregnancies complicated by maternal intrahepatic cholestasis differed greatly from that seen after uncomplicated pregnancy. Two main differences were found. In the disulfate fraction, the concentrations of two pregnanediol isomers, 5alpha-pregnane-3alpha,20alpha-diol and 5beta-pregnane-3alpha,20alpha-diol, were high after cholestasis. Other investigators have shown that, as a result of cholestasis, these pregnanediol sulfates circulate in greatly elevated amounts in the maternal plasma. Our results indicate that in cholestasis these steroids cross the placenta into the fetal compartment, where they circulate in elevated amounts as disulfates. Secondly, the concentrations of several steroid sulfates known to be synthesized by the fetus were significantly lower in the cholestasis group than in the healthy controls. This was especially true of 16alpha-hydroxydehydroepiandrosterone sulfate and 16alpha-hydroxypregnenolone sulfate. These results suggest that, in pregnancies complicated by maternal intrahepatic cholestasis, impairment of fetal steroid synthesis, and especially of 16alpha-hydroxylation, occurs in the fetal compartment.Thus, the changes in maternal steroid metabolism caused by cholestasis are reflected in the steroid profile of the fetoplacental circulation. Furthermore, maternal intrahepatic cholestasis may result in the production of some substance which crosses the placenta and affects fetal steroid metabolism.