17-OHP Levels Research Articles

Newborn screening for congenital adrenal hyperplasia in Srinagarind Hospital, Khon Kaen University, Thailand

Background: Salt wasting 21-hydroxylase deficiency congenital adrenal hyperplasia (CAH) is the most common cause of adrenal insufficiency during neonatal periods. Newborn screening for CAH will improve case early detection and decrease associated morbidity and mortality. The previous nationwide incidence of CAH in 1999 was 1:19,521. To date, CAH newborn screening has not been included in national newborn screening program. Objective: We evaluated the incidence of CAH in newborns delivered at Srinagarind Hospital. Methods: Between September 2005 and June 2008, the filter paper blood spot 17-hydroxyprogesterone (17-OHP) tests were determined in newborns delivered at Srinagarind Hospital. The tests were concurrently performed with TSH and phenylketonuria screening in national newborn screening program of the Ministry of Public Health of Thailand. Re-evaluation with completed physical examinations, repeated blood test for serum 17-OHP and serum electrolytes were performed in newborns who had 17-OHP levels higher than cut-off values. CAH was indicated in patients who had abnormal high serum 17-OHP concentration with or without hyperpigmentation and/or ambiguous genitalia in affected females and/or electrolyte imbalance. Results: Five thousand seven hundred seventy one of 7,147 (80.74%) live births were screened for CAH. Fourteen infants (0.24%) were recalled for re-evaluation. Eight of fourteen (57.14% response rate) infants had the repeated blood tests. Abnormal elevated serum 17-OHP concentrations were found in two infants. Only one had clinical and laboratory findings indicative of CAH. The incidence of CAH was therefore 1:5,771. Conclusion: The incidence of CAH from newborn screening in Srinagarind Hospital was obviously higher than national incidence of Thailand. The implement of CAH screening for all neonates should be reconsidered. Keywords: Congenital adrenal hyperplasia, newborn screening, salt wasting, 17-hydroxyprogesterone, 21-hydroxylase deficiency

Weight-adjusted neonatal 17OH-progesterone cutoff levels improve the efficiency of newborn screening for congenital adrenal hyperplasia

To evaluate weight-adjusted strategy for levels of neonatal-17OHP in order to improve newborn screening (NBS) efficiency. Blood samples collected between 2-7 days of age from 67,640 newborns were evaluated. When N17OHP levels were ≥ 20 ng/mL, and a second sample was requested. We retrospectively analyzed neonatal-17OHP levels measured by Auto DELFIA- B024-112 assay, grouped according to birth-weight: G1: < 1,500 g, G2: 1,501-2,000 g, G3: 2,000-2,500 g and G4: > 2,500 g. 17OHP cutoff values were determined for each group using the 97.5(th), 99(th), 99.5(th) and 99.8(th) percentiles. 0.5% of newborns presented false-positive results using the cutoff level ≥ 20 ng/mL for all groups. Neonates of low birthweight made up 69% of this group. Seven full-term newborns presented congenital adrenal hyperplasia (CAH) and, except for one of them, 17OHP levels were > 120 ng/mL. Only the 99.8(th) percentile presented higher predictive positive value (2%), and lower rate of false-positives in all groups. We suggest the use of 99.8(th) percentile obtained by weight-adjusted N17OHP values of healthy newborns to reduce the rate of false-positive results in NBS.

Congenital Adrenal Hyperplasia: 20-Year Experience in Southern Thailand

Background: Congenital adrenal hyperplasia (CAH) is a group of inherited disorders resulting deficiency of enzymes in the synthesis of cortisol. The clinical symptoms vary depending upon the specific enzymatic deficiency. Aim: To depict the clinical features, and laboratory and hormonal studies of CAH patients. Subjects and method: The medical records of pediatric patients diagnosed with CAH at Songklanagarind Hospital during 1991-2010 were reviewed. Results: There were 61 CAH patients. The most common type was 21-hydroxylase deficiency, salt-wasting type (21-OH, SW) (57.4%), followed by 21-hydroxylase deficiency, simple virilizing type (21-OH, SV) (31.1%). All patients with 20, 22-desmolase deficiency (n=4), 21-OH, SW (n=35) and 3β-hydroxysteroid dehydrogenase deficiency (n=3) presented with dehydration at the median age of 1.8 months. Genital ambiguity was found in 53% of girls with 21-OH, SW. Nineteen patients with 21-OH, SV presented with enlarged clitoris/penis at the median age of 5 years. The median cortisol level after ACTH stimulation was < 18 ug/dL in all types, except 19 patients with 21-OH, SV, in which the median cortisol was 19.49µg/dL. The basal 17-OHP level of these 19 patients was markedly elevated (5,985 ng/dL). All patients, except one, were assigned correctly as a boy or girl at the initial presentation. Conclusions: The most common type of CAH in our institute was 21-hydroxylase deficiency. The most common clinical manifestation in the newborn period is dehydration, and in the childhood period is the enlarged clitoris/penis. The most useful investigation for definite diagnosis of 21-hydroxylase deficiency is basal 17-OHP level.

Association of Prenatal and Postnatal Exposure to Lopinavir-Ritonavir and Adrenal Dysfunction Among Uninfected Infants of HIV-Infected Mothers

Lopinavir-ritonavir is a human immunodeficiency virus 1 (HIV-1) protease inhibitor boosted by ritonavir, a cytochrome p450 inhibitor. A warning about its tolerance in premature newborns was recently released, and transient elevation of 17-hydroxyprogesterone (17OHP) was noted in 2 newborns treated with lopinavir-ritonavir in France. To evaluate adrenal function in newborns postnatally treated with lopinavir-ritonavir. Retrospective cross-sectional analysis of the database from the national screening for congenital adrenal hyperplasia (CAH) and the French Perinatal Cohort. Comparison of HIV-1-uninfected newborns postnatally treated with lopinavir-ritonavir and controls treated with standard zidovudine. Plasma 17OHP and dehydroepiandrosterone-sulfate (DHEA-S) concentrations during the first week of treatment. Clinical and biological symptoms compatible with adrenal deficiency. Of 50 HIV-1-uninfected newborns who received lopinavir-ritonavir at birth for a median of 30 days (interquartile range [IQR], 25-33), 7 (14%) had elevated 17OHP levels greater than 16.5 ng/mL for term infants (>23.1 ng/mL for preterm) on days 1 to 6 vs 0 of 108 controls having elevated levels. The median 17OHP concentration for 42 term newborns treated with lopinavir-ritonavir was 9.9 ng/mL (IQR, 3.9-14.1 ng/mL) vs 3.7 ng/mL (IQR, 2.6-5.3 ng/mL) for 93 term controls (P < .001). The difference observed in median 17OHP values between treated newborns and controls was higher in children also exposed in utero (11.5 ng/mL vs 3.7 ng/mL; P < .001) than not exposed in utero (6.9 ng/mL vs 3.3 ng/mL; P = .03). The median DHEA-S concentration among 18 term newborns treated with lopinavir-ritonavir was 9242 ng/mL (IQR, 1347-25,986 ng/mL) compared with 484 ng/mL (IQR, 218-1308 ng/mL) among 17 term controls (P < .001). The 17OHP and DHEA-S concentrations were positively correlated (r = 0.53; P = .001). All term newborns treated with lopinavir-ritonavir were asymptomatic, although 3 premature newborns experienced life-threatening symptoms compatible with adrenal insufficiency, including hyponatremia and hyperkalemia with, in 1 case, cardiogenic shock. All symptoms resolved following completion of the lopinavir-ritonavir treatment. Among newborn children of HIV-1-infected mothers exposed in utero to lopinavir-ritonavir, postnatal treatment with a lopinavir-ritonavir-based regimen, compared with a zidovudine-based regimen, was associated with transient adrenal dysfunction.

Relationship of CYP21A2 genotype and serum 17-hydroxyprogesterone and cortisol levels in a large cohort of Italian children with premature pubarche

Premature pubarche (PP) is the most frequent sign of nonclassic congenital adrenal hyperplasia (NCCAH) due to 21-hydroxylase deficiency in childhood. The aim of this study was to assess the relationship between the CYP21A2 genotype and baseline and ACTH-stimulated 17-hydroxyprogesterone (17-OHP) and cortisol serum levels in patients presenting with PP. A total of 152 Italian children with PP were studied. Baseline and ACTH-stimulated 17-OHP and cortisol serum levels were measured and CYP21A2 gene was genotyped in all subjects. Baseline and ACTH-stimulated serum 17-OHP levels were significantly higher in NCCAH patients than in both heterozygotes and children with idiopathic PP (IPP). Of the patient population, four NCCAH patients (7.3%) exhibited baseline 17-OHP values <2 ng/ml (6 nmol/l). An ACTH-stimulated 17-OHP cutoff level of 14 ng/ml (42 nmol/l) identified by the receiver-operating characteristics curves showed the best sensitivity (90.9%) and specificity (100%) in distinguishing NCCAH patients. This value, while correctly identifying all unaffected children, missed 9% of affected individuals. Cortisol response to ACTH stimulation was <18.2 μg/dl (500 nmol/l) in 14 NCCAH patients (28%) and none of the heterozygotes or IPP children. Among the 55 NCCAH patients, 54.5% were homozygous for mild CYP21A2 mutations, 41.8% were compound heterozygotes for one mild and one severe CYP21A2 gene mutations, and 3.6% had two severe CYP21A2 gene mutations. In children with PP, baseline 17-OHP levels are not useful to rule out the diagnosis of NCCAH, which is accomplished by means of ACTH testing only. The different percentages of severe and mild CYP21A2 gene mutations found in PP children compared with adult NCCAH patients is an indirect evidence that the enzyme defect is under-diagnosed in childhood, and it might not lead to the development of hyperandrogenic symptoms in adulthood. Stress-dose glucocorticoids should be considered in patients with suboptimal cortisol response to ACTH stimulation.

Relationships of Basal Level of Serum 17-Hydroxyprogesterone with that of Serum Androstenedione and Their Stimulated Responses to a Low Dose of ACTH in Young Adult Patients with Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency

A single measurement of serum 17α-hydroxyprogesterone (17OHP) level can be unreliable because of its marked diurnal variation. We investigated the relationship of serum level of 17OHP with that of androstenedione (AD), which shows a smaller diurnal variation. And we tested whether the responses of these two hormones to low-dose ACTH stimulation are correlated in patients with 21-hydroxylase deficiency. Baseline serum 17OHP and AD levels were measured in 87 patients and a low-dose ACTH stimulation test was performed in 41 patients. The basal 17OHP level correlated positively with the basal AD level independently of sex, type of 21-hydroxylase deficiency, and the time of day of blood sampling (n = 87, R2 = 0.75, P < 0.001). The area under the curve of 17OHP and AD correlated positively with their respective basal levels. The fold-change increase in 17OHP after ACTH injection correlated negatively with the basal 17OHP level, but that of AD did not correlate with the basal AD level. The random serum 17OHP level, used in the clinic, is a reliable guide and a low-dose ACTH stimulation test provides no extra benefit for assessing the treatment adequacy in patients with 21-hydroxylase deficiency.

Neonatal screening for congenital adrenal hyperplasia: transitory elevation of 17-hydroxyprogesterone

The aim of the study was to identify patients with transitory elevation (TE) of 17-hydroxyprogesterone (17-OHP) using neonatal screening for congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21-OHD) and to compare them with patients with 21-OHD. This was a retrospective study of patients with high 17-OHP levels detected during newborn screening in Madrid, Spain. 17-OHP levels were significantly higher in the 33 21-OHD patients, who tended to present hyponatraemia and hyperkalemia. The TE-17-OHP group was characterized by normal initial physical examination (88.8% vs. 39.4%), lower gestational age and a higher number of stressful perinatal factors. 17-OHP levels decreased spontaneously in this group. Molecular diagnosis allowed us to discard the most frequent mutations associated with 21-OHD. Newborns with slightly increased 17-OHP levels and normal results for physical examination, acid-base equilibrium, glycemia, electrolytes and perinatal stress factors should be carefully evaluated. Decisions on treatment should be postponed until these results are available.

The prevalence of testicular adrenal rest tumors and associated factors in postpubertal patients with congenital adrenal hyperplasia caused by 21-hydroxylase deficiency

Development of a testicular adrenal rest tumor (TART) is common in males with congenital adrenal hyperplasia, and it can be an important cause of infertility. In the present study, we observed the prevalence of TARTs, and analyzed its associated factors in patients with 21-hydroxylase deficiency. Testicular ultrasonography was performed in 48 postpubertal male patients aged 10.6 to 27.1 years. To determine whether patients were undertreated, we analyzed the serum 17-hydroxyprogesterone (17-OHP) levels to the time of ultrasonographic measurement and calculated the percentage of measurements when serum 17-OHP level was >10 ng/mL relative to the total number of measurements during the follow-up period. We divided the 6-year period before ultrasonographic measurement (time 0) into three 2-year intervals and calculated the average concentration of serum 17-OHP in each interval to give a -2(nd) to 0 year-average concentration (-2-0YAC), -4-2YAC and -6-4YAC. A TART was detected by ultrasonography in 31 of 48 patients (64.6%) and the median maximal cross-sectional area of the TARTs was 0.71 (0.03, 4.95) cm(2). The corrected final adult height was lower, and -4-2YAC and body mass index were higher in patients with TART than in those without. After controlling for the type of 21-hydroxylase deficiency, hydrocortisone-equivalent dose, age, and -6-4YAC, the size of TART was associated with a high undertreatment percentage with a marginal statistical significance. These results suggest that strict disease control is mandatory and regular examination with testicular ultrasonography is recommended in male patients, regardless of the type of 21-hydroxylase deficiency.

Inappropriate gonadotropin secretion in polycystic ovary syndrome: The relationship with clinical, hormonal and metabolic characteristics

Age of menarche in the group B was signifi cantly later than that in the group A. BMI, waist-hip ratio and blood pressures were signifi cantly lower in the group B compared to those of the group A. Ovarian volume and serum levels of LH, estradiol, total testosterone, sex-hormone binding globulin, 17-hydroxyprogesterone (OHP), and high density lipoprotein were signifi cantly higher in the group B. Postprandial 2 hours glucose, insulin and HOMA-IR were signifi cantly higher in the group A. After adjustment of BMI, the LH/FSH ratio was signifi cantly positively correlated with age at menarche, ovarian volume, total testosterone levels, and 17-OHP levels. Conclusion The inappropriate gonadotropin secretion may be negatively correlated with BMI, and positively with age of menarche and increased ovarian androgen production irrespective of BMI in women with PCOS. However, it may not be associated with metabolic characteristics.

Hyperandrogenism in Women with Polycystic Ovary Syndrome Persists after Menopause

Ovarian and adrenal hyperandrogenism characterize premenopausal women with polycystic ovary syndrome (PCOS). Androgens decline with age in healthy and PCOS women. The objective of the study was to investigate hyperandrogenism in PCOS after menopause. This was a case-control, cross-sectional study. The study was conducted at a university hospital endocrinology unit. Twenty postmenopausal women with PCOS and 20 age- and body mass index-matched controls participated in the study. Serum cortisol, 17-hydroxyprogesterone (17-OHP), Δ(4)-androstenedione (Δ(4)A), dehydroepiandrosterone sulfate (DHEAS), total testosterone (T), and free androgen index (FAI) levels were measured at baseline, after ACTH stimulation, and after 3-d dexamethasone suppression. The ACTH and cortisol levels were measured during the CRH test. Androgen profile at baseline, after ACTH stimulation, and 3-d dexamethasone suppression tests were the main outcome measures. Postmenopausal PCOS women had higher 17-OHP, Δ(4)A, DHEAS, total T, FAI (P < 0.05) and lower SHBG (P < 0.05) baseline levels than control women. ACTH and cortisol responses during the CRH test were similar in the two groups. After ACTH stimulation, Δ(4)A, DHEAS, and total T levels were equally increased in both groups. After dexamethasone suppression, LH levels did not change in either group; 17-OHP-, Δ(4)A-, and FAI-suppressed levels remained higher in PCOS than in control women (P < 0.05), whereas total T and DHEAS levels were suppressed to similar values in both groups. In postmenopausal PCOS women, ACTH and cortisol responses to CRH are normal. Androgen levels at baseline are higher in PCOS than control women and remain increased after ACTH stimulation. The dexamethasone suppression results in postmenopausal PCOS women suggest that DHEAS and total T are partially of adrenal origin. Although the ovarian contribution was not fully assessed, increased Δ(4)A production suggests that the ovary also contributes to hyperandrogenism in postmenopausal PCOS women. In conclusion, postmenopausal PCOS women are exposed to higher adrenal and ovarian androgen levels than non-PCOS women.

Monitoring Medical Treatment in Adolescents and Young Adults with Congenital Adrenal Hyperplasia: Utility of Salivary 17α-Hydroxyprogesterone Day Profiles

Efficacy of medical treatment in patients with 21-hydroxylase deficiency is usually monitored by measurement of 17α-hydroxyprogesterone (17OHP). Saliva instead of serum sampling offers some advantages, such as painless handling and measurement of the bioactive free hormone. This study evaluated the diagnostic validity of salivary 17OHP for monitoring medical treatment, with samples collected at 7 time points throughout a day. Day profiles were performed in 23 adolescents and young adults with 21-hydroxylase deficiency and 43 healthy volunteers. During each profile, saliva and serum samples for 17OHP were simultaneously collected. With regard to the initial day profiles, samples were pathological in 63% (saliva) and 41% (serum). After the first day profile 14 patients underwent adjustment of medical treatment, either because of highly elevated 17OHP levels or with the aim of dose reduction. When comparing the best with the first day profile fewer samples were pathological (saliva: 32% vs. 71%; p<0.05; serum: 21% vs. 47%; n. s.), while the mean hydrocortisone equivalent dose was significantly reduced (20.09 mg vs. 27.27 mg; p<0.01). In 53% of profiles with controlled salivary 17OHP levels at 0700 h, the necessity for a treatment modification became only apparent when analyzing the whole day profile. A single 0700 h value within the reference range does not allow for a reliable assessment of therapeutic efficacy. We therefore suggest 17OHP day profiles for monitoring medical treatment. In this context, saliva analysis appears to be more sensitive in identifying patients who are inadequately treated.

Blood Pressure in the First Year of Life in Children with Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency: A Pilot Study

Aims: Evaluation of blood pressure in the first year of life in children with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Methods: Twenty-four children were included. Retrospective blood pressure values, fludrocortisone dosages, and serum renin, 17-hydroxyprogesterone (17-OHP) and androstenedione levels in the first year of life were evaluated. Blood pressure values were compared to reference values. Correlations between blood pressures and serum renin levels, and the dosage of fludrocortisone were calculated. Results: Mean peak systolic blood pressure values were generally not elevated, most values were around the 50th percentile, except incidentally higher mean peak systolic blood pressure values most below the 95th percentile. No significant correlations between blood pressure and serum renin, androstenedione and 17-OHP levels and fludrocortisone dosage were found. Conclusion: In this pilot studyin CAH patients, blood pressure values do not seem to be elevated in the first year of life. Further investigations are necessary to evaluate blood pressure in the first year of life in CAH patients in more detail.

Molecular analysis of CYP21A2 can optimize the follow‐up of positive results in newborn screening for congenital adrenal hyperplasia

Neonatal screening for congenital adrenal hyperplasia (CAH) is useful in diagnosing salt wasting form (SW). However, there are difficulties in interpreting positive results in asymptomatic newborns. The main objective is to analyze genotyping as a confirmatory test in children with neonatal positive results. Patients comprised 23 CAH children and 19 asymptomatic infants with persistently elevated 17-hydroxyprogesterone (17OHP) levels. CYP21A2 gene was sequenced and genotypes were grouped according to the enzymatic activity of the less severe allele: A1 null, A2 < 2%, B 3-7%, C > 20%. Twenty-one children with neonatal symptoms and/or 17OHP levels > 80 ng/ml carried A genotypes, except two virilized girls (17OHP < 50 ng/ml) without CAH genotypes. Patients carrying SW genotypes (A1, A2) and low serum sodium levels presented with neonatal 17OHP > 200 ng/ml. Three asymptomatic boys carried simple virilizing genotypes (A2 and B): in two, the symptoms began at 18 months; another two asymptomatic boys had nonclassical genotypes (C). The remaining 14 patients did not present CAH genotypes, and their 17OHP levels were normalized by 14 months of age. Molecular analysis is useful as a confirmatory test of CAH, mainly in boys. It can predict clinical course, identify false-positives and help distinguish between clinical forms of CAH.

Assessment of theca cell function prior to controlled ovarian stimulation: the predictive value of serum basal/stimulated steroid levels

Serum androgen levels correlate with ovarian sensitivity to follicle-stimulating hormone (FSH) but in practice, standard baseline serum testosterone (T) levels prior to in-vitro fertilization (IVF) may not be the most appropriate marker for determination. Infertile women enrolled in an IVF programme were included in this study. Serum T and Delta4-androstenedione (A), and the androgen precursor 17-hydroxyprogesterone (17-OHP) were measured before and 24 h after a gonadotrophin-releasing hormone agonist stimulation test (GAST). An early follicular phase antral follicle count (AFC) was also performed. Patients were subsequently enrolled in a long gonadotrophin-releasing hormone agonist protocol with a standard FSH dose (150 IU) for 7 days to assess the association between androgen levels and ovarian responsiveness to FSH. The GAST elicited a significant increase in serum androgen levels that was well correlated with AFC. 17-OHP showed the greatest response to GAST and strongest correlation with AFC. The 17-OHP response to GAST differentiated patients with high ovarian reserve (OR) from those with low or normal OR as assessed by AFC, whereas only the estradiol response could differentiate those with low AFC. GAST-stimulated serum levels of 17-OHP were also correlated with ovarian response to FSH. Using receiver operating characteristic curve analysis, stimulated 17-OHP levels were predictive of the ovarian response to controlled ovarian stimulation, with similar power to that observed with AFC but lower power than with anti-Müllerian hormone. Serum androgen levels following GAST are correlated with AFC and ovarian response to FSH. Serum T is a less sensitive marker of theca cell function than 17-OHP.

Precocious Pubarche: Distinguishing Late-Onset Congenital Adrenal Hyperplasia from Premature Adrenarche

Because precocious pubarche (PP) reveals late-onset congenital adrenal hyperplasia (LO-CAH) in 5 to 20% of cases, an adrenal stimulation test is recommended in all patients presenting with it. This test is stressful and expensive, and results are normal in more than 80% of cases. Our objective was to identify clinical and plasma predictors of LO-CAH among patients presenting with PP. We conducted a retrospective cohort study that included all patients seen for PP at our hospital between 1999 and 2006 (n = 238). All had undergone an ACTH test. LO-CAH was defined by a post-ACTH 17-hydroxyprogesterone (17-OHP) plasma level greater than 10 ng/ml and confirmed by mutational analysis of the CYP21 gene. The association of standard clinical and laboratory indicators with LO-CAH was assessed. Ten (4%) of 238 patients had LO-CAH. Basal 17-OHP, Delta4-androstenedione, and testosterone plasma levels were significantly higher in these patients. A 2-ng/ml threshold for basal 17-OHP plasma levels offered 100% (95% CI, 69-100) sensitivity for the diagnosis of LO-CAH and 99% (95% CI, 96-100) specificity. We identified three plasma predictors of LO-CAH in patients presenting with PP. A selective strategy based on a 2-ng/ml basal 17-OHP plasma level threshold would have safely avoided 99% of the unnecessary ACTH tests among our patients.

Transient hyper-17-hydroxyprogesteronemia: a clinical subgroup of patients diagnosed at neonatal screening for congenital adrenal hyperplasia

Neonatal screening for congenital adrenal hyperplasia (CAH) is characterized by a high false-positive rate, mainly among preterm and low birth weight infants. The aims of this study were to describe a subgroup of infants with transient serum hyper-17-hydroxyprogesteronemia (hyper-17-OHPemia) and to compare them with false positive and affected by 21-hydroxylase deficiency newborns. We retrospectively analyzed the clinical data of all newborns positive at CAH neonatal screening, who were referred to our hospital to confirm the diagnosis from 2002 to 2006. They were submitted to clinical investigations and blood tests to evaluate 17-hydroxyprogesterone (17-OHP), renin, and electrolyte levels. CAH-unaffected newborns with increased serum 17-OHP were submitted to strict follow-up monitoring, which included an ACTH-stimulating test and genetic analysis of the 21-hydroxylase gene, until serum 17-OHP decreased. Thirty-seven newborns with gestational ages ranging from 33 to 40 weeks were studied. Eight infants (three male and five female) were affected by CAH (serum 17-OHP: 277.5 (210-921) nmol/l), 14 (ten male and four female) were false positives (17-OHP: 3.75 (0.3-8.4) nmol/l), and 15 (ten male and five female) showed a serum hyper-17-OHPemia (17-OHP: 15.9 (9.9-33) nmol/l). No mutations of the 21-hydroxylase gene were found in infants with hyper-17-OHPemia and their serum 17-OHP levels were normalized by the third month of life. We identified a population of infants with transient serum hyper-17-OHPemia, and no clinical signs of disease or 21-hydroxylase gene mutations. No further investigations are necessary after birth in these newborns if 17-OHP levels decrease, other confirmatory tests such as ACTH-stimulation test or genotyping analysis are necessary only if symptoms appear.

21-Deoxycortisol (21-DF) and 17-hydroxyprogesterone (17-OHP) responses to adrenalcorticotropic hormone in males with idiopathic oligozoospermia.

Combined results of 21-DF (via the specific RIA method) and 17-OHP levels in plasma were used to support the evidence that some of the cases with idiopathic oligozoospermia (I.O.) are the result of 21-hydroxylase deficiency (C-21-HD). In our current tests, in four out of 19 males with I.O., elevated levels of 21-DF prior to ACTH stimulation (24.3 +/- 2.3 ng/dl) and after ACTH stimulation (81.2 +/- 5.2 ng/dl) in comparison to the controls (10.6 +/- 4.3 ng/dl and 36.9 +/- 10.1 ng/dl after ACTH) and other I.O. cases were observed. Only one out of these cases presented elevated 17-OHP levels prior and after ACTH stimulation in comparison to the controls and other I.O. cases. Measuring the 21-DF levels along with the 17-OHP in males suspected of C-21-HD, seems to aid the establishing of a correct diagnosis.

Non-classical 21-hydroxylase deficiency: prevalence in males with unexplained abnormal sperm analysis

To evaluate the prevalence of nonclassical 21-hydroxylase deficiency (NC-21OHD) in men with abnormal sperm parameters of unexplained etiology compared with males with normal sperm analysis. Case control study. Major tertiary medical center. Of 484 healthy men being followed at a fertility clinic, 222 (mean age 33.8 +/- 6.1 [+/-SD] years) presented with abnormal findings on sperm analysis (1999 WHO criteria) of unknown cause and 262 (mean age 34.8 +/- 6.5 [+/-SD] years) with a normal sperm analysis. Random mid-morning blood sampling to test for 17-hydroxyprogesterone (17-OHP) levels. Subjects with levels of >or= 6 nmol/L underwent a standard adrenocorticotropic hormone (ACTH) stimulation test. NC-21-OHD, defined as a stimulated ACTH level of >or=45 nmol/L. A serum 17-OHP level of >or=6 nmol/L was detected in 11 study patients (5.0%) and 14 control subjects (5.3%). Seven study patients and 8 controls subsequently underwent ACTH stimulation test, and none had levels compatible with a diagnosis of NC-21OHD. Mean 17-OHP levels were similar in the two groups (3.3 +/- 1.4 [+/-SD] nmol/L and 3.3 +/- 1.5 [+/-SD] nmol/L, respectively). There was no correlation between sperm parameters and serum 17-OHP levels. Until larger studies are performed, the routine measurement of 17-OHP in the evaluation of male infertility is not recommended.

H62L Mutation of CYP21A2 Identified in the Non-classical Form of 21-Hydroxylase Deficiency

Neonatal mass screening for congenital adrenal hyperplasia (CAH) has been performed in Japan since 1989. Steroid 21-hydroxylase deficiency (21-OHD) represents about 95% of CAH patients and is traditionally divided into three forms, severe classical salt-wasting (SW), simple virilizing (SV) and the milder non-classical (NC) form. Very rare cases of the NC form have been detected because of elevated 17-hydroxyprogesterone (17-OHP) levels at neonatal mass screening in Japan (1). The estimated rate of detection of the NC form by mass screening seems to be low (1:1,100,000) (1). This disease is caused by deletions or mutations of CYP21A2. In Japan, the P30L mutation appears more likely to be associated with Japanese NC patients (1). Here, we report a rare H62L mutation with the NC form in a Japanese 21-OHD patient.

Measurement of Serum 17.ALPHA.-hydroxyprogesterone in Newborn Infants by Stable Isotope Dilution-Gas Chromatography/Mass Spectrometry

Immunochemical measurement of serum 17α-hydroxyprogesterone (17OHP), the most important parameter for diagnosis of classical 21-hydroxylase deficiency (21OHD) in newborn infants, is known to be inaccurate due to the cross-reactivity of antibodies with a large quantity of fetal adrenal steroids. The aims of this study were 1) to establish reference values for the serum 17OHP level in Japanese newborn infants using non-immunochemical stable isotope dilution —gas chromatography/mass spectrometry (SID-GC/MS) and 2) to compare the serum 17OHP levels determined by SID-GC/MS with those determined by radioimmunoassay (RIA). The first study subjects were used for determination of reference values and included 57 healthy full-term newborn infants (4–5 d of age). The second study subjects were used for comparison of SID-GC/MS with RIA and included 27 healthy full-term newborn infants (3–6 d of age) and two subjects with neonatal transient hyper 17OHPnemia; these two subjects were 16 and 27 d of age, respectively. In the first study subjects, the intra-assay coefficient of variation for SID-GC/MS was 3% (n=5), the recovery rate was 98%, the sensitivity was 0.2 ng/ml, and the range of linearity was 0.5–200 ng/ml. The reference values for the serum 17OHP level determined by SID-GC/MS ranged from 0.3–1.5 (0.6) (ng/ml) (median). In the second study subjects, the serum 17OHP levels determined by SID-GC/MS were lower in one of the 27 subjects and both of the two subjects with neonatal transient hyper 17OHPnemia compared with the levels determined by RIA. Measurement of the serum 17OHP level using SID-GC/MS may be clinically useful for definitive diagnosis of classical 21OHD in newborn infants.