Diagnosis Of Congenital Adrenal Hyperplasia Research Articles

Atypical Congenital Adrenal Hyperplasia (CAH) Presentation of A Patient, Resulting in A Similar Diagnosis for His Sibling

Introduction: Congenital adrenal hyperplasia (CAH) is the commonest cause of primary adrenal insufficiency and is known to be transmitted in an autosomal recessive manner. We report two cases of male siblings with CAH. Cases: The elder sibling was diagnosed late at 4 years old with signs of virilization, complicated with central precocious puberty (CPP). The younger sibling was diagnosed after baseline screening and stimulation test. Treatment with both hydrocortisone and fludrocortisone were commenced for both siblings once the diagnosis was made. The elder sibling however, required treatment with gonadotropin analogues to treat the CPP.  Conclusion: These cases illustrate the importance of an early diagnosis of CAH and the benefit of screening siblings to prevent late presentations of CAH in high-risk families.

Increased risk of nephrolithiasis: an emerging issue in children with congenital adrenal hyperplasia due to 21-hydroxylase deficiency

PurposeTo investigate the incidence of nephrolithiasis in a cohort of children with congenital adrenal hyperplasia (CAH), and to study if there is an association with the metabolic control of the disease.MethodsThis study was designed as a multicenter 1 year-prospective study involving 52 subjects (35 males) with confirmed molecular diagnosis of CAH due to 21-hydroxylase deficiency (21-OHD). Each patient was evaluated at three different time-points: T0, T1 (+6 months of follow-up), T2 (+12 months of follow up). At each follow up visit, auxological data were collected, and adrenocorticotrophic hormone (ACTH), 17-hydroxyprogesterone (17-OHP), Δ4-androstenedione, dehydroepiandrosterone sulfate (DHEAS) serum levels, and urinary excretion of creatinine, calcium, oxalate and citrate were assayed. Moreover, a renal ultrasound was performed.ResultsThe incidence of nephrolithiasis, assessed by ultrasound was 17.3% at T0, 13.5% at T1 and 11.5% at T2. At T0, one subject showed nephrocalcinosis. In the study population, a statistically significant difference was found for 17-OHP [T0: 11.1 (3.0–25.1) ng/mL; T1: 7.1 (1.8–19.9) ng/mL; T2: 5.9 (2.0–20.0) ng/mL, p < 0.005], and Δ4-androstenedione [T0: 0.9 (0.3–2.5) ng/mL; T1: 0.3 (0.3–1.1) ng/mL; T2: 0.5 (0.3–1.5) ng/mL, p < 0.005] which both decreased over the follow up time. No statistically significant difference among metabolic markers was found in the group of the subjects with nephrolithiasis, even if 17-OHP, DHEAS and Δ4-androstenedione levels showed a tendency towards a reduction from T0 to T2. Principal component analysis (PCA) was performed to study possible hidden patterns of associations/correlations between variables, and to assess the trend of them during the time. PCA revealed a decrease in the amount of the variables 17-OHP, Δ4-androstenedione, and ACTH that occurred during follow-up, which was also observed in subjects showing nephrolithiasis.Conclusionsour data demonstrated that children affected with 21-OHD can be at risk of developing nephrolithiasis. Additional studies are needed to clarify the pathogenesis and other possible risk factors for this condition, and to establish if regular screening of kidney ultrasound in these patients can be indicated.

Parental concerns about genital differences in children with congenital adrenal hyperplasia persist regardless of the selected intervention.

Congenital Adrenal Hyperplasia (CAH) due to 21-hydroxylase deficiency (21HD) can affect the in utero development of the genital anatomy of people with the 46XX karyotype. Health professionals engage parents in decision-making regarding managing genitals with this difference, including genital surgery options and patient communication. We sought to investigate parental communication with their daughters regarding clitoral size variation related to neonatal CAH. Semistructured in-person interviews of 24 parents of chromosomal XX children with clitoral size variation attributable to a neonatal CAH diagnosis comprised 3 management categories: (1) clitoral reduction surgery (RS) (7 parents, 9 children), (2) clitoral concealment surgery (CS) (8 parents, 8 children), and no surgery on or around the clitoris (NS) (9 parents, 7 children). Four representative themes, Obvious Choice, Still Different, Parental Burden, and Ignorance Is Bliss, were common across all 3 treatment groups. For most parents, none of the 3 options of genital appearance alteration via clitoral reduction, clitoral concealment surgery, or avoidance of clitoral surgery ameliorated concerns, with most parents expressing an aversion to educating their child on the topic of genital differences, past treatment, or future function. Reliance on surgical treatment pathways to manage this psychosocial concern is ineffective in alleviating parental uncertainty without the application of psychosocial interventions. This was a qualitative study but was limited to parents of children with a specific genital difference, without direct exploration of parental values regarding the clitoris or the application of adequate psychosocial care. Healthcare services must have an impact on parental ability to engage in essential communication with their children in cases such as clitoral size variation related to neonatal CAH. Improved communication skills allow parents to engage in more genuine decision-making and adapt to enduring genital reality, including possible future sexual challenges for their adult child, without resorting to burdensome strategies focused on attempts to perpetuate a benevolent ignorance.

Prenatal diagnosis of congenital adrenal hyperplasia due to 21-hydroxylase deficiency through molecular genetic analysis of the CYP21A2 gene.

Deficiency of 21-hydroxylase (21-OHD) is an autosomal recessively inherited disorder that is characterized by adrenal insufficiency and androgen excess. This study was performed to investigate the clinical utility of prenatal diagnosis of 21-OHD using molecular genetic testing in families at risk. This study included 27 pregnant women who had previously borne a child with 21-OHD. Fetal tissues were obtained using chorionic villus sampling (CVS) or amniocentesis. After the genomic DNA was isolated, Sanger sequencing of CYP21A2 and multiplex ligation-dependent probe amplification were performed. The clinical and endocrinological findings were reviewed retrospectively. A total of 39 prenatal genetic tests was performed on 27 pregnant women and their fetal tissues. The mean gestational age at the time of testing was 11.7 weeks for CVS and 17.5 weeks for amniocentesis. Eleven fetuses (28.2%) were diagnosed with 21-OHD. Among them, 10 fetuses (90.9%) harbored the same mutation as siblings who were previously diagnosed with 21-OHD. Among these, 4 fetuses (3 males and 1 female) identified as affected were born alive. All 4 patients have been treated with hydrocortisone, 9α-fludrocortisone, and sodium chloride since a mean of 3.7 days of life. The male patients did not show hyponatremia and dehydration, although they harbored pathogenic variants associated with the salt-wasting type of 21-OHD. This study demonstrated the diagnostic efficacy and clinical consequences of diagnosis by prenatal genetic testing in families at risk for 21-OHD. All patients identified as affected were treated with hydrocortisone and 9α-fludrocortisone early after birth, which can prevent a life-threatening adrenal crisis.

CYP21A2 Gene Analysis in Southern Iranian CAH Patients and a Brief Review of the Mutation Spectrum.

CYP21A2 gene mutations are responsible for more than 95% of Congenital Adrenal Hyperplasia (CAH) disorders with autosomal recessive inheritance. Most of these pathogenic mutations originate from the CYP21A1P, a neighboring pseudogene with 98% homology, due to unequal crossing over or gene conversion events. Mutation identification of the gene could be beneficial for accurate diagnosis and outcome prediction. Twelve unrelated patients with CAH diagnosis were recruited for genetic counseling. To ensure distinct amplification of the CYP21A2 gene rather than its pseudogene, the complete sequence of the gene was amplified through two overlapping fragments by specific primers. The entire sequences were screened by direct Sanger sequencing using new sequencing primers. Only two pathogenic point mutations were identified. The c.293-13C>G, also known as In2G, and the c.955C>T mutations were found in 37.5 and 33.3% of alleles, respectively. One patient showed homozygous gene deletion. We also reviewed recent reports on CYP21A2 gene mutations in Iran. Evaluating the ethnicity-specific gene mutation data is significant for populations with diverse ethnic groups including the Iranian population. Although several common mutations have been reported as causative mutations among CAH patients, identifying only two common point mutations in Fars province would help prioritize exon sequencing and reduce the cost and time of genotyping.

A comprehensive LC-MS/MS method for the simultaneous measurement of 24 adrenal steroids: From research to clinical practice

Steroids are essential in the differential diagnosis of congenital adrenal hyperplasia (CAH) subtypes; however, they may confuse physicians with multifarious results. In this study, we established a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for the simultaneous measurement of 24 steroids and developed a steroid metabolite pathway-based report to aid physicians in understanding these results. Solid-phase extraction was used to concentrate and purify target plasma steroids. The linearity, precision, recovery, and matrix effects were thoroughly evaluated. PowerBuilder was used to transfer the results from LC-MS/MS to the graphic report in a laboratory information management system (LIS) and was applied to different subtypes of CAH. Twenty-four steroids were separated and analyzed in one sample preparation and two injections using LC-MS/MS. The linearity of the steroids was excellent, with coefficients of linear regression greater than 0.99. The relative recovery ranged from 90.0 to 107.1 %, whereas the intra- and total coefficient variations were 1.6 ∼ 8.7 % and 2.0 ∼ 9.9 %, respectively. Matrix effects were compensated after internal standard correction. A graphic combination report mode was established and used to effectively identify CAH subtypes. In conclusion, a useful LC-MS/MS method and graphic combination report of 24 steroids based on their metabolite pathways were established.

Salt-Wasting Congenital Adrenal Hyperplasia in A 2-Year-Old Patient

Congenital Adrenal Hyperplasia (CAH) is an autosomal recessive disorder due to deficiencies of enzymes involved in steroidogenesis in the adrenal cortex. It is known that 90% of CAH are due to 21-hydroxylase enzyme deficiency caused by mutation of the CYP21A2 gene. A female patient aged two years and one month old was reported with a diagnosis of salt-wasting CAH. The diagnosis was based on complaints of genital enlargement since birth. The patient had developed repeated vomiting and severe dehydration since newborn. The patient was diagnosed with CAH and under treatment with glucocorticoid replacement therapy by a pediatrician since the age of 5 months. Body height/age &lt; -3 Standard Deviation (SD) of the Z-score chart (very short stature) and ambiguous genitalia were reported. Laboratory tests indicated thrombocytosis (795x103/uL), mild hyperkalemia (5.4 mmol/L), and increased testosterone (110.1 ng/dL). Bone age study affirmed an advanced bone age. History of increased 17-hydroxyprogesterone (109.19 ng/mL) and decreased morning serum cortisol levels (1.7 ug/dL). History of gynecological ultrasonography (USG) showed uterus, no bilateral testicular structure, hyperplasia of the left adrenal gland, and suggestive of genital ambiguity. The 21-hydroxylase deficiency causes a decrease in aldosterone and cortisol and an increase in androgens. Hypoaldosteronism causes hypovolemia, hyponatremia and hyperkalemia. Hypocortisolime causes hypoglycemia, decreased response to infection, and stress. Hyperandrogenism causes virilization of the genitalia and short stature in patients. A female patient aged two years and one month old was reported with a salt-wasting congenital adrenal hyperplasia diagnosis. Chromosome analysis was the recommended test in this case.

Cardiovascular risk in Cuban adolescents and young adults with congenital adrenal hyperplasia

BackgroundHyperandrogenism and supraphysiologic glucocorticoid replacement may lead to subclinical atherosclerosis in people with congenital adrenal hyperplasia (CAH) and predispose the development of cardiovascular diseases from an early age.ObjectivesTo determine if cardiometabolic risk factors and subclinical atherosclerosis are more frequent in patients with CAH due to 21-hydroxylase deficiency (21OHD) and if there is an association with clinical, hormonal and treatment of 21OHD.Material and methodsA descriptive prospective cross-sectional study exploring clinical variables, biochemical, hormonal variables, endothelial dysfunction (flow-mediated dilation < 5%) and carotid intima media thickness (≥ 95 percentile in adolescents and ≥ 75 percentile in adults) and epicardial fat. Adolescents and young patients with 21OHD were compared with controls matched by age, sex, body mass index and Tanner stage.ResultsForty four subjects (22 with CAH), 36 (82%) females, with a mean age of 17.1 ± 5.5 years (range 10–30 years) were included. Family history revealed diabetes, hypertension, and hypercholesterolemia with high frequencies in both groups. The blood pressure was similar in both groups. Blood glucose levels were lower and triglycerides higher in patient (both p < 0.01). Epicardial fat was similar between groups and in patients with CAH it was related to cholesterol levels ​​(r = 0.679, p < 0.01), time since CAH diagnosis (r = 0.462, p = 0.03) and glucocorticoid dose (r = 0.499, p = 0.04). Carotid intima media thickness (CIMT) had a tendency to be increased in patients (p = 0.07) and was directly related to 17-hydroxyprogesterone (r = 0.510, p = 0.018), diastolic blood pressure (r = 0.444, p = 0.04) and the homeostatic model assessment (HOMA) index (r = 0.507, p = 0.01). Endothelial dysfunction was not different between groups.ConclusionsSome cardiometabolic risk factors were increased in patients with CAH and were associated with clinical, hormonal and treatment parameters of CAH. Cardiometabolic risk should be evaluated regularly in patients with CAH.

Hormonal control during infancy and testicular adrenal rest tumor development in CAH males - a retrospective multi-center cohort study.

Testicular adrenal rest tumors (TART), often found in male patients with congenital adrenal hyperplasia (CAH), are benign lesions causing testicular damage and infertility. We hypothesize that chronically elevated adrenocorticotropic hormone (ACTH) exposure during early life may promote TART development. This study aimed to examine the association between commencing adequate glucocorticoid treatment early after birth and TART development. This retrospective multicenter (n = 22) open cohort study collected longitudinal clinical and biochemical data of the first 4 years of life using the I-CAH registry and included 188 male patients (median age 13 years; IQR: 10-17) with 21-hydroxylase deficiency (n = 181) or 11-hydroxylase deficiency (n = 7). All patients underwent at least one testicular ultrasound. TART were detected in 72 (38%) of the patients. Prevalence varied between centers. When adjusted for CAH phenotype, a delayed CAH diagnosis of more than 1 year, compared to a diagnosis within 1 month of life, was associated with a 2.6 times higher risk of TART diagnosis. TART onset was not predicted by biochemical disease control or bone age advancement in the first four years of life, but increased height SDS at the end of the four-year study period was associated with a 27% higher risk of TART diagnosis. A delayed CAH diagnosis of more than 1 year versus CAH diagnosis within one month after birth was associated with a higher risk of TART development, which may be attributed to poor disease control in early life.

FRI251 A Combination Of Klinefelter Syndrome And The Classic Form Of Congenital Dysfunction Of The Adrenal Cortex: Clinical Case

Abstract Disclosure: N.I. Volkova: None. Introduction: Congenital adrenal hyperplasia (CAH) is a defect in one of the enzymes or transport proteins involved in the synthesis of cortisol in the adrenal cortex. Virile form of CAH is characterized by cortisol deficiency and hyperandrogenism. Klinefelter syndrome is one of the most frequent chromosomal diseases leading to the development of primary hypogonadism. The manifestation of these two diseases in one patient causes difficulties in diagnosis and medical treatment that leads to adverse consequences. Clinical Case: A 43-years-old patient consulted a physician complaining about the lack of erections for 4 years, breast enlargement. From anamnesis, it is known: that the patient at the age of 2 years and 8 months based on experienced growth of pubic hair, decreased level of 17-ketosteroids in the urine and genetic analysis diagnosis of CAH, virile form was suspected. Prednisone 5 mg daily was prescribed. At the age of 5, based on phenotypic features and karyotyping Klinefelter Syndrome (XXY) was diagnosed. At the age of 13, stimulating hormonal chorionic gonadotropin drug with only one course of 10 injections was prescribed. At the age of 18, the patient independently canceled the use of prednisone. Further, he did not receive medication therapy for CAH and Klinefelter syndrome. At the age of 42, adrenal CT revealed formation of the left adrenal gland. High levels of aldosterone and renin were detected. A diagnosis of left adrenal aldosteroma was made and a left-sided adrenalectomy was performed. Histological examination diagnosis of aldosteroma did not confirmed. On physical examination, BMI 30 kg/m2, genoid type of obesity, right testicle is not palpated, left testicle is dense, reduced in size. Small penis size.Laboratory examination revesled decreased level of total testosterone, normal level of SHBG, LH and FSH. Ultrasound of the scrotum organs revealed as well decrease in the size of the testicles and appendages, a volumetric formation of the right testicle, suspicious of tumor. Thus, diagnosis of CAH, virile form and Klinefelter syndrome, primary hypogonadism, right-sided cryptorchidism was confirmed. Hydrocortisone 30 mg daily was prescribed. Hormone replacement therapy with testosterone preparations was not prescribed until surgical treatment of neoplasm of the right testicle will be performed. Conclusion: We have demonstrated a combination of two endocrine pathologies and serious mistakes were made in the management of this patient that requires a multidisciplinary approach, which improves the prognosis and quality of life of these patients. Presentation: Friday, June 16, 2023

The impact of neonatal 17-hydroxyprogesterone cutoff determination in a public newborn screening program for congenital adrenal hyperplasia in Southern Brazil: 3 years' experience.

Congenital adrenal hyperplasia (CAH) occurs due to enzyme defects in adrenal steroidogenesis. The 21-hydroxylase deficiency accounts for 90-95% of cases, triggering accumulation of 17-hydroxyprogesterone (17-OHP). Early diagnosis through neonatal screening allows adequate treatment and reduced mortality. The purpose of the study was to determine 17-OHP cutoffs for the diagnosis of CAH in a public newborn screening program in Southern Brazil. A retrospective, descriptive, cross-sectional study was conducted to analyze 17-OHP levels in dried blood samples collected on filter paper of 317,745 newborns screened at a public newborn screening center from May 2014 to April 2017. Neonatal 17-OHP was measured in DBS samples using a time-resolved fluoroimmunoassay (GSP® kit 3305-0010; PerkinElmer). Different cutoffs were determined and stratified by birth weight. The incidence of CAH was 1:15,887 live births in the state of Rio Grande do Sul, with 20 cases of classical CAH diagnosed during the study period. Most newborns (80.73%) were white, and the prematurity rate was 9.8% in the study population. The combination of different percentiles, 98.5th for birth weight 2001-2500 g and 99.8th for the other birth weight groups, decreased false-positive results and increased specificity compared with current reference values to identify classical CAH cases. The local 17-OHP cutoffs determined were higher than those currently used by this screening program for all birth weight groups. The calculation of reference values from local population data and the combination of percentiles proved to be a valuable tool for proper diagnosis of CAH and reduction in the number of false positives.

THE IMPORTANCE OF NEWBORN SCREENING FOR THE DIAGNOSIS OF CONGENITAL ADRENAL HYPERPLASIA: LITERATURE REVIEW

Introduction: Congenital adrenal hyperplasia (CAH) is a metabolic condition that involves many different clinical manifestations and specificities, caused by genetic abnormalities that are associated with phenotypic enzyme deficiencies. It is one of the many pathologies included in the Brazilian newborn screening, demonstrating its importance. Objectives: Present a bibliographic review about the importance of newborn screening in diagnosing CAH, emphasizing the physiopathology of the disease and its epidemiologic and social relevance. Method: A literature review was done using the following databases: Biblioteca Virtual em Saúde (BVS), Scielo, PubMed and Lilacs. Results: The early diagnosis of CAH is crucial to the reduction of complications from this pathology, being that the neonatal screening is mainly aimed at detecting the classic salt-wasting form that is the most serious and potentially life-threatening form for the child. Conclusion: Expanding the screening tests and making them more widely available to the population is essential to minimize the risks.

Genetic Characterization of a Cohort of Italian Patients with Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency.

Defects in the steroid 21-hydroxylase gene (CYP21A2) cause 21-hydroxylase deficiency (21OHD), the main cause of congenital adrenal hyperplasia (CAH). The disease shows a broad spectrum of clinical forms, ranging from severe or classical (salt wasting, SW, and simple virilizing, SV), to mild late onset or nonclassical (NC). 21OHD affects 1 in 15,000 in its severe classic form and 1 in 200-1000 in its mild NC form. There are many studies reporting the frequency of CYP21A2 pathogenic variants in different populations; however, few of them provide comprehensive information about Italian patients. Here, we present genetic results from a cohort of 245 unrelated Italian individuals with clinical diagnosis of CAH due to 21OHD. A specific polymerase chain reaction (PCR) protocol combined with Sanger sequencing was used for CYP21A2 analysis. The multiplex ligation-dependent probe amplification (MLPA) assay was employed for copy number variation (CNV) determination. One hundred fourteen (46.5%) of the index cases had the NC form, 57 (23.3%) had the SV form, and 74 (30.2%) presented the SW form of the disease. The most prevalent variant found in NC patients was the p.Val282Leu (51.3%), while the most frequent variants in the classical form were p.Ile173Asn (8.6%) and c.293-13C>G (26.0%). In our study, the frequency of large rearrangements was 15.3%, with CAH-X alleles representing 40% of all DEL/CONV. In addition, 12 alleles carried rare variants, and 1 had a novel variant p.(Arg342Gln). We observed phenotype-genotype correlation in 94.7% of cases. A complete concordance was observed in Groups 0 (enzyme activity completely impaired) where all patients had the SW form as expected. In Group A (0-1% residual enzyme activity), 78.4% of patients had the anticipated SW form while 21.6% were diagnosed with the SV form. Within Group B (~2% residual enzyme activity), 93.4% of patients exhibited SV form and 6.5% SW disease. Finally, 92.6% and 7.4% of patients belonging to Group C (enzyme partially impaired to ~20-60% residual activity) exhibited NC and SV phenotypes, respectively. This work, representing a comprehensive genetic study, expanded the CYP21A2 variants spectrum of Italian patients with 21OHD and could be helpful in prenatal diagnosis and genetic counseling.

[Consensus on laboratory diagnosis of congenital adrenal hyperplasia due to 21 hydroxylase deficiency].

21 hydroxylase deficiency (21-OHD), the most common form of congenital adrenal hyperplasia, is caused by defects in CYP21A2 gene, which encodes the cytochrome P450 oxidase (P450C21) involved in glucocorticoid and mineralocorticoid synthesis. The diagnosis of 21-OHD is based on the comprehensive evaluation of clinical manifestation, biochemical alteration and molecular genetics results. Due to the complex structure of CYP21A2, special techniques are required to perform delicate analysis to avoid the interference of its pseudogene. Recently, the state-of-the-art diagnostic methods were applied to the clinic gradually, including the steroid hormone profiling and third generation sequencing. To standardize the laboratory diagnosis of 21-OHD, this consensus was drafted on the basis of the extensive knowledge, the updated progress and the published consensuses and guidelines worldwide by expert discussion organized by Rare Diseases Group of Pediatric Branch of Chinese Medical Association, Medical Genetics Branch of Chinese Medical Doctor Association, Birth Defect Prevention and Molecular Genetics Branch of China Maternal and Child Health Association. and Molecular Diagnosis Branch of Shanghai Medical Association.

P-588 A comparison of obstetrical and neonatal outcomes in patients with the hyperandrogenic states, polycystic ovarian syndrome(PCOS) and congenital adrenal hyperplasia(CAH): a retrospective population-database study.

Abstract Study question PCOS and CAH are associated with increases in pregnancy complications. Therefore, we evaluated differences in pregnancy and neonatal outcomes between women with PCOS and CAH. Summary answer When comparing these conditions PCOS was associated with pregnancy-induced hypertension and gestational diabetes, whereas CAH had more cesarean sections and small for gestational age infants. What is known already PCOS and CAH are causes of hyperandrogenism among women of reproductive age. Apart from causing hyperandrogenism, they also share characteristics such as menstrual irregularity, polycystic ovaries and insulin resistance with central adiposity. Several meta-analyses have associated PCOS with adverse obstetrical and neonatal outcomes with most studies finding an increased frequency of pregnancy-induced hypertension (PIH), preeclampsia, gestational diabetes (GDM), cesarean section (CS) and preterm delivery. CAH on the other hand, is associated with higher rates of CS and inconsistent evidence about increases in GDM, chorioamnionitis and congenital anomalies. Study design, size, duration A retrospective population-based study utilizing data from the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS), was performed. A dataset of all deliveries between 2004 and 2014 inclusively, was created. Within this group, all deliveries to women who had a diagnosis of PCOS or CAH and pregnancy were identified. Each subject had a delivery or maternal death to be included once per pregnancy. Participants/materials, setting, methods Descriptive analyses were performed to compare the demographic features among both groups, for which chi-squared tests were used. Multivariate logistic regression analysis was performed to calculate unadjusted and adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CI) and correct for any difference in baseline demographics (P &amp;lt; 0.05) between the groups. According to the Tri-Council Policy statement (2018), institutional review board (IRB) approval was not required, given that data was anonymous and publicly available. Main results and the role of chance A total of 15,179 women with either PCOS or CAH were included. Approximately 98% of those women (14,881) were diagnosed with PCOS, while the rest 2% (298) had CAH. The adjusted analysis for race, obesity, previous CS, multiple gestation and IVF yielded the following results. For pregnancy outcomes PIH (aOR=1.76; 95% CI: 1.12-2.77; p = 0.015) and GDM (aOR=1.68; 95% CI: 1.12-2.52; p = 0.012) were more common among women with PCOS, whereas no statistically significant results were detected for rates of placenta previa, preeclampsia or eclampsia superimposed on pre-existing hypertension or eclampsia. After additional adjusting for PIH and GDM, the delivery outcomes showed CS to be significantly less common in the PCOS group (aOR=0.59; 95% CI 0.44-0.80; p &amp;lt; 0.001), with no significant differences concerning preterm premature rupture of membranes, preterm delivery, abruptio placenta, chorioamnionitis, operative vaginal delivery, hysterectomy, postpartum hemorrhage, wound complications, maternal death and need for transfusion. In neonatal outcomes, women with CAH had higher percentages of SGA neonates (aOR=0.32; 95% CI 0.20-0.52; p &amp;lt; 0.001) and no difference in intrauterine fetal demise and congenital anomalies. Limitations, reasons for caution The limitations of our study are its retrospective nature and the fact that it relies on an administrative database. Furthermore, CAH type was not specified. Information on medication use and compliance was also lacking information about certain potential confounders such as parity, and duration of labor. Wider implications of the findings This is the first study to investigate the differences in obstetrical and neonatal outcomes between these two hyperandrogenic disorders and we noted that the majority of risks were similar, despite the difference in the pathophysiology of these conditions. Rates of certain complications differ and studies are needed to elucidate why. Trial registration number N/A

Long-read sequencing: An effective method for genetic analysis of CYP21A2 variation in congenital adrenal hyperplasia

BackgroundThe sequence similarity between CYP21A2 gene and its inactive pseudogene CYP21A1P, and copy number variation (CNV) caused by unequal crossover, make it challenging to characterize the CYP21A2 gene through traditional methods. This study aimed to evaluate the clinical utility of the long-read sequencing (LRS) method in carrier screening and genetic diagnosis of congenital adrenal hyperplasia (CAH) by comparing the efficiency of the LRS method with the conventional multiplex ligation-dependent probe amplification (MLPA) plus Sanger sequencing approaches in CYP21A2 analysis. MethodsIn a retrospective study, full sequence analysis of the CYP21A2 and CYP21A1P was performed for three pedigrees through long-range locus-specific PCR followed by LRS based on the Pacific Biosciences (PacBio, California, USA) single-molecule real-time (SMRT) platform, and the results were compared with those obtained from next-generation sequencing (NGS)-based whole exome sequencing (WES) and the traditional methods of MLPA plus Sanger sequencing. ResultsThe LRS method successfully identified seven CYP21A2 variants, including three single nucleotide variants (NM_000500.9:c.1451G > C p.(Arg484Pro), c.293-13A/C > G (IVS2-13A/C > G), c.518 T > A p.(Ile173Asn)), one 111-bp polynucleotide insertion, one set of 3′URT variants (NM_000500.9:c.*368 T > C, c.*390A > G, c.*440C > T, c.*443 T > C) and two types of chimeric genes and straightforwardly depicted the inheritance patterns of these variants within families. Moreover, the LRS method enabled us to determine the cis–trans configuration of multiple variants in one assay, without the need to analyze additional family samples. Compared with traditional methods, this LRS method can achieve a precise, comprehensive and intuitive result in the genetic diagnosis of 21-hydroxylase deficiency (21-OHD). ConclusionThe LRS method is comprehensive in CYP21A2 analysis and intuitive in result presentation, which holds substantial promise in clinical application as a crucial tool for carrier screening and genetic diagnosis of CAH.

The pathogenic p.Gln319Ter variant is not causing congenital adrenal hyperplasia when inherited in one of the duplicated CYP21A2 genes.

The study aimed to identify the pathogenic status of p.Gln319Ter (NM_000500.7: c.955C>T) variant when inherited in a single CYP21A2 gene (bimodular RCCX haplotype) and to discriminate between a non-causing congenital adrenal hyperplasia (CAH) allele when inherited in a duplicated and functional CYP21A2 gene context (trimodular RCCX haplotype). 38 females and 8 males with hyperandrogenemia, previously screened by sequencing and identified as carriers for the pathogenic p.Gln319Ter, were herein tested by multiplex ligation-dependent probe amplification (MLPA) and a real-time PCR Copy number Variation (CNV) assay. Both MLPA and real-time PCR CNV analyses confirmed a bimodular and pathogenic RCCX haplotype with a single CYP21A2 in 19/46 (41.30%) p.Gln319Ter carriers and who in parallel all shared elevated 17-OHP levels. The remaining 27 individuals that also carried the p.Gln319Ter exhibited low 17-OHP levels as a result of their carriership of a duplicated CYP21A2 with a trimodular RCCX haplotype. Interestingly, all of these individuals also carried in linkage disequilibrium with p.Gln319Ter two single nucleotide polymorphisms, the c.293-79G>A (rs114414746) in intron 2 and the c.*12C>T (rs150697472) in the 3'-UTR. Therefore, these variants can be used to distinguish between pathogenic and non-pathogenic genomic contexts of the c.955T (p.Gln319) in the genetic diagnosis of congenital adrenal hyperplasia (CAH). The employed methodologies identified a considerable number of individuals with non-pathogenic p.Gln319Ter from the individuals that typically carry the pathogenic p.Gln319Ter in a single CYP21A2. Therefore, it is extremely important the detection of such haplotypes for the prenatal diagnosis, treatment and genetic counseling in patients with CAH.

When the history of the disease is the key to diagnosis: About a challenging case of congenital adrenal hyperplasia

Background: A 17 alpha-hydroxylase deficiency (17OHD) is a rare form of congenital adrenal hyperplasia (CAH). Congenital adrenal hyperplasia (CAH) is a group of disorders resulting from defect of one of enzymes necessary for biosynthesis of cortisol. Case: A 33-year-old female suffered from 17OHD. She presented with primary amenorrhea, lack of secondary sexual characteristics, and hypertension complicated by ruptured cerebral aneurysm. Laboratory tests showed hypokalemia, low levels of androgens (testosterone and dehydroepiandrosterone), corticosteroid, and high levels of adrenocorticotropic hormone and progesterone. The clinical manifestations, imaging and laboratory results appeared to be consistent with a diagnosis of CAH in the patient, due to the observed 17α‑hydroxylase deficiency. Conclusion: 17OHD is a rare disease associated with primary amenorrhea and hypertension. This case shows the importance of vital signs measurement, medical history and commitment to a systematic approach.

Non-classical congenital adrenal hyperplasia. Clinical case

Congenital adrenal hyperplasia (CAH) is an autosomal recessive disease emerging from mutations of genes for enzymes that lead to the biochemical shifts in the production of glucocorticoids, mineralocorticoids, or sex steroids from cholesterol by the adrenal glands. Universal newborn screening for CAH is recommended for early diagnosis and initiation of therapy. The development of CAH is due to a defect in the CYP21 gene, which encodes 21-hydroxylase enzyme involved in the synthesis of cortisol. This leads to an increase in the secretion of adrenocorticotropic hormone and the accumulation of cortisol precursors, which are converted into adrenal androgens— the classical form of the disease develops. With a point mutation of the CYP21 gene, an incomplete defect occurs in 21-hydroxylase, which leads to an unpronounced disorder of adrenal steroidogenesis— a non-classical form of congenital adrenal hyperplasia, which happens more often. In this form, the clinical symptoms are erased with moderate hirsutism, acne vulgaris, infertility. In comparison to the classical form of the disease, which is diagnosed at birth or during the neonatal period because of ambiguous genitalia and/or salt-wasting symptoms or through screening programs used in some countries, most cases of non-classical CAH are not easy to detect. Additionally, many individuals remain asymptomatic during childhood and adolescence, have normal reproductive function, and only become aware of non-classical CAH due to the diagnosis of another family member and consequent testing. However, most women with non-classical CAH seek medical assistance when they experience symptoms of androgen excess and, when clinical suspicion prompts testing, elevated basal 17-OH progesterone levels may primarily point to the diagnosis of non-classical CAH. A case of a non-classical form of the disease which manifested itself in infertility is given. Pregnancy occurred after 4 months treatment with prednisolone (5 mg/day).

Congenital Adrenal Hyperplasia and Human Leukocyte Antigen B: A Meta-Analysis.

The link between specific human leukocyte antigen (HLA)-B genes and congenital adrenal hyperplasia (CAH) has been a subject of interest. This study investigates the association between specific HLA-B haplotypes and CAH through a meta-analysis. Google Scholar was used as a database. Articles were included if the research was conducted between 1970 and 2022, was not a meta-analysis, and had odds ratios or enough data points to calculate an odds ratio. The National Institutes of Health (NIH) quality assessment tool of case-control studies was used to evaluate the risk of bias in individual studies, and MetaXL was used to generate data and create a forest plot for analysis. Twelve studies met the selection criteria and were included in the study (641 patients and 3,614 controls). Two HLA-B haplotypes showed increased odds of CAH compared to controls: B14 (OR=3.81; 95%CI=2.88, 5.05; I2=3%) and B35 (OR=1.88; 95%CI=1.22, 2.90; I2=25%). All other HLAs either showed no significant effect or had high heterogeneity. The results suggest that specific HLA-B haplotypes have increased odds of developing CAH, specifically B14 and B35. These findings may prove helpful in the pre- and post-natal diagnosis of CAHas well as the identification of carriers and prediction of patient prognosis.