Nonclassic Congenital Adrenal Hyperplasia Research Articles

Некласична вроджена гіперплазія кори надниркових залоз унаслідок дефіциту 21-гідроксилази: лабораторні критерії діагностики й контролю ефективності лікування

Некласична вроджена гіперплазія кори надниркових залоз (НВГКНЗ) унаслідок дефіциту 21-гідроксилази є однією з актуальних причин гіперандрогенних проявів у різні вікові проміжки часу. Своєчасна діагностика цього захворювання потребує обов’язкового включення визначення базальних рівнів 17-оксипрогестерону (17-ОПГ) у комплексне обстеження пацієнтів різних вікових груп із клінічними проявами надлишку андрогенів. Особливо це важливо при обстеженні дівчаток-підлітків і жінок репродуктивного віку з клінікою гіперандрогенії. В обов’язковий комплекс обстеження жінок при встановленні діагнозу синдрому полікістозних яєчників має входити виключення некласичної ВГКНЗ відповідно до всіх світових рекомендацій. При отриманні рівнів 17-ОПГ у діапазоні 2–10 нг/мл необхідно провести пробу з козинтропіном, що визнана у світі як стандарт діагностики ВГКНЗ. Діагностичним порогом постановки діагнозу ВГКНЗ унаслідок дефіциту 21-гідроксилази є рівень 17-ОПГ, базальний чи стимульований у пробі, понад 10 нг/мл. Проведення генетичного тестування — визначення мутацій у гені CYP21A2 — є важливим і необхідним інструментом не тільки підтвердження діагнозу, але й визначення тактики лікування пацієнта з діагнозом некласичної ВГКНЗ і виявлення ризиків появи класичної форми в майбутньої дитини за наявності алелі, пов’язаної з класичною формою вродженої дисфункції кори надниркових залоз у майбутніх батьків. За основу лабораторних критеріїв постановки діагнозу взято рекомендації останнього керівництва Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline, 2018.

The Application of Principal Component Analysis on Clinical and Biochemical Parameters Exemplified in Children With Congenital Adrenal Hyperplasia.

PurposePrincipal component analysis (PCA) is a mathematical model which simplifies data into new, combined variables. Optimal treatment of pediatric congenital adrenal hyperplasia (CAH) remains a challenge and requires evaluation of all biochemical and clinical markers. The aim of this study was to introduce PCA methodology as a tool to optimize management in a cohort of pediatric and adolescent patients with CAH by including adrenal steroid measurements and clinical parameters.MethodsThis retrospective, longitudinal cohort of 33 children and adolescents with CAH due to 21-hydroxylase deficiency included 406 follow-up observations. PCAs were applied to serum hormone concentrations and compared to treatment efficacy evaluated by clinical parameters.ResultsWe provide and describe the first PCA models with hormone parameters denoted in sex- and age-adjusted standard deviation (SD) scores to comprehensibly describe the combined ‘endocrine profiles’ of patients with classical and non-classical CAH, respectively. Endocrine profile scores were predictive markers of treatment efficacy for classical (AUC=92%; accuracy 95%; p=1.8e-06) and non-classical CAH (AUC=80%; accuracy 91%; p=0.004). A combined PCA demonstrated clustering of patients with classical and non-classical CAH by serum 17-hydroxyprogesterone (17-OHP) and dehydroepiandrosterone-sulphate (DHEAS) concentrations.ConclusionAs an example of the possibilities of PCA, endocrine profiles were successfully able to distinguish between patients with CAH according to treatment efficacy and to elucidate biochemical differences between classical and non-classical CAH.

Should the approach to non-classic congenital adrenal hyperplasia (NCAH) be changed? - a real-life validation of NCAH diagnostic process

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Management of Fully Pubertal Girls With Nonclassical Congenital Adrenal Hyperplasia: Glucocorticoids Versus Oral Contraceptives

ObjectiveTo compare clinical outcomes of 3 treatment regimens—glucocorticoids (GCs), oral contraceptives (OCs), or a combination of both—administered to adolescents and young women diagnosed in childhood with nonclassical congenital adrenal hyperplasia (NCCAH), who had been treated with GCs until their adult height was achieved. MethodsA retrospective study of medical records of 53 female patients with NCCAH followed in 3 tertiary pediatric endocrinology institutes. The 3 treatment groups were compared for the prevalence of hirsutism and acne, standardized body mass index (BMI)-standard deviation score (SDS), and androgen levels at the attainment of adult height (baseline), 1-year later, and at the last documented visit. ResultsAt baseline, there were no significant differences among groups in BMI-SDS, androgen levels, hirsutism prevalence, acne, or irregular menses. From baseline to the last visit, the rate of hirsutism declined significantly only in the OC group (37.5% vs 6.2%, respectively; P = .03). The rate of acne declined in the combined group (50% vs 9%, respectively; P = .03) with a similar tendency in the OC group (50% vs 12.5%, respectively; P = .05). No significant changes were observed in BMI-SDS for the entire cohort or any subgroup during follow-up. A significant rise in androstenedione (P < .001), testosterone (P < .01), and 17-hydroxyprogesterone (P < .01) levels was observed only in the OC group. ConclusionIn girls diagnosed in childhood with NCCAH, who require treatment for hyperandrogenism following completion of linear growth, management should be tailored individually using a patient-centered approach. Treatment with OCs might be better than that with GCs for regression of hirsutism and acne. The long-term effects of elevated levels of androgens associated with this treatment regimen should be further studied.

Establishing a new screening 17 hydroxyprogesterone cut-off value and evaluation of the reliability of the long intramuscular ACTH stimulation test in the diagnosis of nonclassical congenital adrenal hyperplasia.

Nonclassical congenital adrenal hyperplasia (NCAH) is a common genetic transmitted endocrinological disease. The validity of screening by using a 17 hydroxyprogesterone (17 OH-P) cut-off level of 2 ng/ml is controversial due to the frequent overlap with the polycystic ovary syndrome (PCOS). The availability of the standard intravenous cosyntropin (ACTH) formula is a problem in many countries including our country and the diagnostic test is performed by using the intramuscular depot form. In this study, we aimed to determine our own cut-off value for screening and to test the reliability of long intramuscular ACTH stimulation test in our patients. One hundred and seventy-five fertile age women whose basal follicular phase 17 OH-P level above 2 ng/ml were included in the study. All of the patients underwent an intramuscular long cosyntropin (ACTH) stimulation test. 17 OH-P levels were above 10 ng/ml in 16 of 175 (9.14%) patients who were compatible with the diagnosis of NCAH. There was no significant difference between NCAH, PCOS and idiopathic hyperandrogenism (IH) groups in terms of hirsutism and hyperandrogenemia. In ROC analysis, 3.19 ng/ml was found to be a reliable cut-off value (AUC: 0.698, 95% GA: 0.540-0.855, p <0.05). In the extended intramuscular ACTH stimulation test, sensitivity increased from 56.2% to 91.6% at 180th minute CONCLUSIONS: Our study gives a perspective about the detection of screening threshold value for the diagnosis of NCAH and the availability of the intramuscular long ACTH stimulation test.

A Broken Pathway: Understanding Congenital Adrenal Hyperplasia in the Newborn.

Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder that leads to the partial or complete deficiency of cortisol and aldosterone production from the adrenal glands. The lack of these key hormones can precipitate acute adrenal crisis during the newborn period. This disorder can further lead to the development of virilized female genitalia from exposure to increased levels of androgens during fetal development. Nonclassical CAH is a common autosomal disorder, affecting 1/200 live births. The classical form of CAH affects 1/10,000-16,000 live births. Infants affected by classic CAH manifest with severe complications and an increased mortality risk. Early identification of CAH is critical to prevent significant sequela of adrenal crisis and to support families of affected females as they work through decisions of gender assignment. Newborn and pediatric nurses, as well as advanced practice providers, should maintain an active working knowledge of CAH to identify affected individuals early, implement needed interventions, and support families through education.

Disorders of Sex Development.

Disorders of Sex Development.

Non-Classic Congenital Adrenal Hyperplasia in Two Adolescents With Gender Dysphoria

The care of transgender individuals is multidisciplinary including medical, surgical, psychiatric, and psychological health professionals. We here report 2 cases of nonclassic congenital adrenal hyperplasia (CAH) coincidently discovered during the clinical and biochemical evaluation prior to hormonal treatment for gender dysphoria. Elevated 17-OH-progesterone and androstenedione led to further investigations including adrenocorticotropic hormone stimulation test and genetic evaluation of 21CYPA2 confirming the diagnosis of CAH in both individuals. The findings may have implications for future surgical treatment and in the case of transwomen for the choice of antiandrogenic treatment. These cases therefore confirm the importance of thorough clinical and biochemical evaluation of transgender individuals before initiation of hormone therapy.

Genetic aetiology of primary adrenal insufficiency in Chinese children

BackgroundPrimary adrenal insufficiency (PAI) is life-threatening, and a definitive aetiological diagnosis is essential for management and prognostication. We conducted this study to investigate the genetic aetiologies of PAI in South China and explore their clinical features.MethodsSeventy children were enrolled in this cross-sectional study. Clinical information was collected, and combined genetic tests were performed according to the children’s manifestations. Statistical analysis was performed among the different groups. In silico or in vitro experiments were applied to determine the pathogenicity of novel variants.ResultsAmong the 70 children, 84.3% (59/70) were diagnosed with congenital adrenal hyperplasia (CAH), and 21-hydroxylase deficiency (21-OHD) was genetically confirmed in 91.5% of these cases. Salt wasting (SW), simple virilization (SV), and non-classic (NC) CAH accounted for 66.1% (39/59), 30.5% (18/59), and 3.4% (2/59) of the cases, respectively. The 17-hydroxyprogesterone (17-OHP) and testosterone (TES) levels were significantly higher in children with SW than with SV. The 17-OHP and cortisol levels in female SW patients were significantly higher than those in males. The 17-OHP, cortisol, dehydroepiandrosterone (DHEAS) and TES levels in female SW patients were significantly higher than those in female SV patients. Additionally, 72.7% (8/11) of uncharacterized PAI patients had positive genetic findings. Among all the patients, two novel variants in the CYP21A2 gene (c.833dupT and c.651 + 2T > G) were found. A microdeletion (Xp21.2–21.3) and five novel variants, including 2 in the NR0B1 gene (c.323–324CG > GA and c.1231_1234delCTCA), 2 in the AAAS gene (c.399 + 1G > A and c.250delT) and 1 in the NNT gene (c.2274delT), were detected. The novel variant c.399 + 1G > A in the AAAS gene was further confirmed to lead to exon 4 skipping during mRNA transcription and produce a truncated ALADIN protein.ConclusionsWe found ethnicity-based differences in the CYP21A2 gene variant spectrum among different study populations. Female 21-OHD patients tended to have higher 17-OHP and TES levels, which warrants caution in relation to the effects of virilization. Novel gene variants detected in the CYP21A2, NR0B1, AAAS and NNT genes expanded the genetic spectrum of PAI, however, further improvement of genetic testing tools beyond our protocol are still needed to uncover the complete aetiology of PAI in children.

Non-Classical Congenital Adrenal Hyperplasia-Causing Alleles in Adolescent Girls with PCOS and in Risk Group for PCOS Development.

Background: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women. Depending on the diagnostic criteria applied, it occurs in up to 16.6% of the general female population. Congenital adrenal hyperplasia includes a group of autosomal recessive disorders, the most common of which is non-classical congenital adrenal hyperplasia (NCAH) caused by mutations in the CYP21A2 gene. PCOS and NCAH have similar clinical manifestations (hyperandrogenemia, i.e., hirsutism, acne, alopecia, and increased androgen levels in the blood) and potential impact on long-term health (infertility, increased risk of type 2 diabetes, and cardiovascular disease. Consequently, it is thought that NCAH mutations in the heterozygous state may play a role in PCOS development and phenotypic expression. Objective: To determine the prevalence of the most common pathogenic alleles of the CYP21A2 gene in adolescents with PCOS and adolescents at risk of PCOS development, and to compare the results with healthy adolescents matched for gynecological age. Methods: A cross-sectional study was conducted with 55 PCOS patients, 23 risk patients (with hyperandrogenism but a normal menstrual cycle), and 49 healthy adolescents. Genetic variations in the CYP21A2 gene were analyzed using a standard Multiplex Ligation-dependent Probe Amplification test (SALSA MLPA Probemix P050-C1 CAH; MRC Holland). Results: No significant differences were found among the three groups regarding the frequency of carriers of NCAH variations in the heterozygous state. It was found that the I172N carrier in the PCOS group had a significantly higher Global Acne Grading Scale score than PCOS patients without this variation (p = 0.038). Within the control group of healthy adolescents, compound heterozygous carriers (IVS2-12A > G and -113G > A) had a significantly higher body mass index than non-carriers (p = 0.036). Conclusion: We found no differences in the incidence of NCAH-causing variations in the heterozygous state in adolescent PCOS patients, risk adolescents (with hirsutism but normal menstruation), and healthy adolescents. Future studies of larger cohorts and rarer pathogenic CYP21A2 gene variations are required.

Quality of life in children diagnosed with non-classic congenital adrenal hyperplasia

Quality of life in children diagnosed with non-classic congenital adrenal hyperplasia

Unnecessary cosyntropin stimulation tests for nonclassic congenital adrenal hyperplasia (NCAH) – shall the cut-off value of 17-hydroxyprogesterone be revised?

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

What Cut-off Value of 17-Hydroxyprogesterone Should Be an Indication to Perform a 250 µg Cosyntropin Stimulation Test When NCCAH Is Suspected? - a Retrospective Study

The Nonclassic Congenital Adrenal Hyperplasia (NCCAH) is a less severe form of CAH in which the activity of the 21-hydroxylase is estimated at about 20% to 50%. Cosyntropin stimulation test is the gold diagnostic standard used to test for this condition. The study was aimed at verifying the currently accepted threshold of 17-hydroxyprogesterone (17OHP) level (≥2.0 ng/mL) at which cosyntropin stimulation test should be performed. Material and methods. The study included 343 patients (328 females and 15 males) referred for a cosyntropin stimulation test due to suspected NCCAH. The median age at the time of evaluation was 27 years. Serum 17-OHP was measured with ELISA assay using Ledect96 Microplate Reader. The NCCAH diagnosis was made if cosyntropin-stimulated 17OHP level exceeded 10.0 ng/mL. The ROC curve was determined, and the cut-off point with the highest sensitivity and specificity was established. The study was approved by the Ethics Board of JUMC. Results:. Symptoms, which prompted testing for NCCAH, most often were: hirsutism in 187 patients, irregular menstrual cycles in 178 patients, and acne in 138 patients. A total of 79 patients (77 females and two males) were diagnosed with NCCAH based on cosyntropin stimulation test results. Seventy-one of them had baseline levels of 17OHP≥2.0 ng/mL. The mean age of patients with confirmed NCCAH was 28.86 years. The baseline 17OHP cut-off value that qualified patients best for testing was 2.79 ng/mL in our group, with sensitivity and specificity of 77.2% and 91.3%, respectively. The sensitivity and specificity for a guideline-recommended cut-off point (17OHP ≥2.0 ng/mL) was 86.1% and 76%, respectively. In five of six patients with secondary amenorrhea and a baseline level of 17OHP ≥2.0 ng/mL, NCCAH was confirmed in a cosyntropin stimulation test. Conclusions:. Our results suggest considering an upward shift in the 17OHP threshold at which patients suspected for NCCAH should be referred for further evaluation. This may reduce the number of unnecessary cosyntropin stimulation tests, mainly that patients with mild phenotype (or asymptomatic) frequently may not require any treatment. However, attention should be paid to patients with coexisting secondary amenorrhea and 17OHP levels ≥2.0 ng/mL, which may be a clinical predictor of NCCAH.

Lack of Hirsutism in an XX Woman With History of Hyperandrogenism and Oligomenorrhea: Two Coexisting Disorders or Novel Syndrome of Androgen Insensitivity?

Polycystic ovary syndrome (PCOS) is one of the most common causes of infertility in women, and its etiologies have not been clearly elucidated. Non-classical congenital adrenal hyperplasia (NC-CAH) with mild to moderate enzyme deficiency of 21-hydroxylase due to bi-allelic mutations in its gene (CYP21A2) is a cause of secondary PCOS that should always be considered. Common clinical features of NC-CAH include menstrual irregularities, hirsutism, acne, advanced bone age with accelerated linear growth, and short stature, associated with hyperandrogenism. Androgen insensitivity syndrome (AIS) is another cause of hyperandrogenism due to lack of response to androgen typically in genetic male (XY) presenting with female physical characteristics, most commonly due to a mutation in the androgen receptor (AR) gene on the X chromosome. Here, we present a 61 years old woman, with a diagnosis of PCOS based on oligomenorrhea and high testosterone ~90 pg/mL at age 18, meeting both NIH and Rotterdam PCOS diagnostic criteria. She took oral contraceptive pills only for one year, despite continued menstrual irregularities. After age 42, her menstrual cycles became and remained regular without further intervention until menopause at age 51, while her testosterone levels fluctuated between 80 and 250 pg/mL. After menopause, her testosterone levels drastically increased to >350 pg/mL. The patient has been recommended, but reluctant to undergo oophorectomy for enlarged non-cystic ovaries. Other potentially related clinical features include the presence of a pituitary adenoma, and a thyroid nodule. She has no notable adrenal mass or myelolipoma. Patient is lean and well-fit, at 5’11” and 151 lb. The most puzzling feature has been a lack of virilization and hirsutism. During laboratory evaluation, high 17-hydroxyprogesterone was identified, and NC-CAH became a potential etiology of PCOS, but this did not explain the lack of apparent virilization. The finding of unimpressive levels of DHEA implied that this pathway probably was unlikely the major cause of high testosterone. Investigation for hyperandrogenism focusing on AIS revealed normal female karyotype XX, and no identifiable mutations or abnormal copy number in AR. The findings thus far have provided no unifying diagnosis for her clinical features, especially for androgen insensitivity, and additional studies are being performed. Assessment of other genes recently reported to be associated with AIS is being performed as well as genetic confirmation of NC-CAH by analyzing CYP21A2. Steroid 5-alpha reductase 2 (SRD5A2), whose mutations and polymorphism interestingly are associated with AIS and PCOS, respectively, and nuclear receptor subfamily 5, group A, member 1 (NR5A1) is another gene associated with AIS. It remains to be determined whether she has AIS as a coexisting disorder with NC-CAH or a novel syndrome with a feature of androgen insensitivity.

Post Menopausal Hyperandrogenism: A Case of a Steroid Cell Tumor of the Ovary

Introduction: Postmenopausal hyperandrogenism is a rare condition that causes hirsutism, virilization, and clitoromegaly that should be carefully evaluated in order to avoid overlooking an androgen secreting tumor (1). Case: A 48 year old African American female with a prior history of polycystic ovarian syndrome (PCOS) presented for evaluation of hirsutism. Of note, she also underwent menopause at age 41 after receiving chemotherapy for a history of multiple myeloma, and she has been on steroids since the time of her diagnosis. On exam, she had thick, dark hair growth on her chin, upper lip, and chest, as well as male-patterned baldness, acne, easy bruising, proximal muscle weakness, deep voice, and elevated blood pressure. Prior to endocrinology evaluation, she was started on spironolactone 25 mg BID. Lab work up included dehydroepiandrosterone sulfate (DHEAS) 73 mcg/dL (27-240 mcg/dL), 17-hydroxyprogesterone 74 ng/dL (31-455 ng/dL), androstenedione 271 ng/dL (30-200 ng/dL), total testosterone 763 ng/dL (8-60 ng/dL), bioavailable testosterone 244 ng/dL (0.8-10 ng/dL), hemoglobin A1c 4.3%, follicle stimulating hormone 30 IU/L, luteinizing hormone 23.9 IU/L, insulin 11 mcIU/mL (2.6-24.9 mcIU/mL), glucose 71, insulin-like growth factor 1 236 ng/mL (44-227 ng/mL) with subsequent normal glucose suppression test. While transvaginal ultrasound did not note any abnormal findings, a computed tomography of the abdomen/pelvis showed a new hyperdense focus in the left ovary as well as a tiny right adrenal nodule, most likely an adenoma. Follow up magnetic resonance imaging confirmed a 1.6 cm enhancing solid left ovarian mass; it also confirmed a right adrenal adenoma and left adrenal thickening versus a tiny adenoma. Urine metanephrines and catecholamines were normal. Patient had total hysterectomy and bilateral oophorectomy; pathology showed a steroid cell tumor. Conclusion: Postmenopausal hyperandrogenism has several causes: insulin resistance, PCOS, non-classic congenital adrenal hyperplasia, medications, and tumors of the ovaries or adrenals. Severe hyperandrogenemia should raise the suspicion of an ovarian or adrenal neoplasm, necessitating prompt imaging (1). Certain imaging may not reveal smaller masses, and additional imaging or ovarian/adrenal vein sampling may be needed. Typically, an elevated DHEAS with a high testosterone suggests an adrenal source, while androstenedione can be elevated in both glands. Once identified, the involved gland is surgically resected. This patient was found to have a steroid cell tumor, which has malignant potential. They make up less than 0.1% of all ovarian tumors (2). Initial treatment is surgical resection and may necessitate chemotherapy if malignant.1) Markopoulos MC, Kassi E, Alexandraki KI, Mastorakos G, Kaltsas G. Hyperandrogenism after menopause. Eur J Endocrinol. 2015 Feb;172(2):R79-91. doi: 10.1530/EJE-14-0468. Epub 2014 Sep 15. PMID: 25225480.2) Hayes, Mary C. M.D.; Scully, Robert E. M.D. Ovarian Steroid Cell Tumors (Not Otherwise Specified), The American Journal of Surgical Pathology: November 1987 - Volume 11 - Issue 11 - p 835-845

Taking it with a Grain of Salt: A Woman with ‘PCOS’ and Infertility Diagnosed with Nonclassic Congenital Adrenal Hyperplasia and a Large Renal Mass

Background: Clinical manifestations of Nonclassic CAH (NCCAH) in women may range from asymptomatic to hirsutism, oligo-menorrhea, or infertility. Testicular adrenal rest tumors are common in men with classic CAH though uncommon in NCCAH. In women with classic CAH, ovarian adrenal rest tumors are even rarer. 11–58% of patients with classic CAH will have at least one adrenal nodule but the prevalence is unknown in NCCAH (1).Clinical Case: A 34-year-old Hispanic woman was seen by reproductive endocrinology for evaluation of infertility. She had been unable to conceive for the past 7 years. She was diagnosed with PCOS by her PCP. She was referred to our clinic for further workup. The patient denied galactorrhea. Laboratory evaluation revealed prolactin 49.3 (< 20.0 ng/ml), TSH 2.290 (0.5–5.0 μU/mL), fT4 1.14 (0.9–2.3 ng/dL), total testosterone 92 (15 -70 ng/dL for women), DHEAS 361 (45 -270 µg/dL), 8 AM cortisol 20.0 (5–23 μg/dL), ACTH 59.0 (6–76 pg/ml), 17-hydroxyprogesterone (17OHP) >2000 ng/dL, and A1c 5%. 24-hour urinary free cortisol was 26.4 (3.5–45 mcg/day). MRI of the pituitary did not show any adenoma. Pelvic ultrasound did not reveal any ovarian cysts.Cosyntropin stimulation test showed baseline 17OHP 1076 ng/dL, 30 minutes 8812 ng/dL, and 60 minutes 9452 ng/dL. She was begun on hydrocortisone and cabergoline. CT of the abdomen did not reveal any adrenal masses but showed mildly thickened adrenal limbs suggesting adrenal hyperplasia. A 4.5 cm exophytic enhancing mass on the left kidney was noted representing an adrenal rest tumor versus angiomyolipoma.Given the exophytic nature of the mass and increased risk of hemorrhage with angiomyolipomas greater than 4 cm, the patient was referred to urology and interventional radiology for radioembolization and possible biopsy of the mass. We are unsure if this renal mass is an angiomyolipoma or an adrenal rest tumor, which are uncommon in the kidneys. The patient was also referred for genetic counseling. Patients with CAH typically have CYP21A2 gene mutations, and the chance that a patient with NCCAH will have a child with classic CAH is reported to be 1 to 2% in two large cohort studies (2).Conclusion: This case is a reminder that evaluation of infertility/subfertility includes less common diagnoses, such as NCCAH. This genetic disorder is seen more frequently in certain ethnic groups, including Hispanics; and after diagnosis, patients should be referred to a genetic specialist. Additional abdominopelvic imaging should be considered in both men and women with a new diagnosis of NCCAH to evaluate for rare but clinically significant tumors.Reference: 1. Nordenström, A., Falhammar H. Diagnosis and management of the patient with non-classic CAH due to 21-hydroxylase deficiency Eur J Endocrinol. 2019 Mar;180(3):R127-R145.2. Merke, D, Auchus, R Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. NEJM 2020;383:1248–61.

Steroid Cell NOS in a Child: A Rare Case Report

Introduction: Steroid cell tumors are rare sex chord tumours of the ovary with malignant potential. Here we report a case of steroid cell NOS in a 12-year-old girl & similarity of the clinical presentation with non-classic congenital adrenal hyperplasia.Clinical Case: 12-yr girl came with complaints of hirsutism since many years and a recent change in voice. There was no past history suggestive of adrenal crisis. On examination she had muscular body habitus, moderate hirsutism (FG score 19), acne. SMR B1, P4, A3. Karyotype 46 XX. BA 13yrs. DHEAS- 144, serum cortisol 8am-14ug/dl. Testosterone-8.35ng/ml (normal 0.1-0.9ng/ml). serum 17 (OH) Progesterone basal-16.37 ng/ml(N-0.2-1.3ng/ml). Post synacthen 17OHP >35ng/ml, LH- <0.1, FSH- 0.2(prepubertal range). U/S-adrenals normal, right ovary was enlarged in size, 4x3cm cystic lesion. A CECT ABDOMEN showed Rt ovary -homogenously enhancing fairly well-defined solid lesion. Differential diagnosis was: NC/SVCAH with ovarian rest tumours vs ovarian virilising tumour. Since there was no non-invasive way of confirming between both the diagnosis, we gave a trial with hydrocortisone to see if her 17OHP reduces. After 1 month of therapy with hydrocortisone,17 OHP was still elevated -17.08ng/ml. Since there was no response, she underwent ovarian biopsy/excision. Right ovarian cystectomy was done. HPE showed -consider1. Steroid cell tumour NOS 2. Adrenal rest tumour. Note that these 2 tumours have identical morphology & IHC features. Followup:2 mon post-surgery: B5 P4 A3, mild facial hair,17 OHP - 1.53 ng/ml, Testosterone 2.5 ng/dl.12 months post-surgery child attained menarche had regular menstrual cycles, Serum 17OHP- 0.41 ng/ml, testosterone-11ng/dl.Conclusion: The usual differential diagnosis in 46 XX female children presenting with signs of androgen excess is CAH, it is not uncommon to find SVCAH presenting in childhood with symptoms & signs of virilisation. Clinically both SV CAH and Steroid cell tumours can present with hyperandrogenic features in the childhood. Amongst steroid cell tumours, 3 subtypes are seen, they include 1. stromal luteoma 2. Leydig cell tumour 3. steroid cell tumour NOS. The steroid cell tumours of the ovary secrete androstenedione, alpha hydroxy progesterone & testosterone .17OHP is raised in both the conditions. The HPE of both adrenal rest tumours & steroid cell NOS is similar & a clear-cut differentiation cannot be made. They are similar in clinical presentation, biochemistry & HPE. It is important to recognise that steroid cell tumour NOS is a differential to SVCAH in childhood. Since these tumours can occur at any age, clues to differentiate both conditions are-raised 17OHP but normal DHEAS & on imaging- normal adrenals with enlarged ovaries with or without solid cystic lesions in steroid cell NOS of the ovary.

Cardiac Arrest in a Child with Non-classic Lipoid Congenital Adrenal Hyperplasia Associated with a New STAR Gene Mutation

Abstract Introduction: Steroidogenic acute regulatory (STAR) protein regulates steroid hormone synthesis by transporting cholesterol into mitochondria. STAR gene mutations lead to lipoid congenital adrenal hyperplasia (LCAH), the rare but most severe form of congenital adrenal hyperplasia in children. We present an unusual case with an episode of cardiac arrest in a young girl during an acute febrile illness and later she was diagnosed with adrenal insufficiency secondary to a non-classic LCAH. Case: 2-year 11-month-old previously healthy white female was brought to an urgent care clinic due to severe lethargy and a seizure-like activity during a fever illness. She was found to have an undetectable blood glucose level and went into cardiac arrest shortly after arrival. CPR was performed for approximately 11 minutes. She then developed sever respiratory distress and was intubated. She was transferred to the PICU with IV sodium bicarbonate given en route. On admission, her body weight was 13.26 kg (36.80th percentile), height 90 cm (17.56th percentile), and BMI 16.17 (62.88th percentile). Her physical exam revealed normal external female genitalia and normal skin pigmentation. Lab evaluation revealed normal sodium and potassium but elevated anion gap, hyperuricemia, elevated creatinine kinase, abnormal liver function tests and abnormal coagulation profile. Brain MRI revealed findings consistent with hypoxic-ischemic encephalopathy. Renal function improved within 24 hours and hepatic function returned to normal after 20 days. Due to her severe hypoglycemic event, a high-dose ACTH stimulation test was performed. The results were consistent with adrenal insufficiency: baseline cortisol level, 7.3 μg/dL; 30 minutes cortisol, 7.8 μg/dL; 60 minutes cortisol, 9 μg/dL (normal response, ≥18 mcg/mL at 30 or 60 minutes). The baseline ACTH level was significantly elevated, 1688 pg/mL (0–46) as well as the renin activity, 24.3 ng/hour (1.7–11.2). Genetic testing revealed a 46 XX karyotype. STAR gene analysis identified compound heterozygosity; a novel deletion (c.811delC, p.Leu271Cysfs*50) and a previously reported missense mutation (c.661G&amp;gt;A, p.Gly221Ser). The girl is now 11 years old and exhibits normal growth, normal cognitive development, and she has developed early signs of puberty (Tanner stage 2 for breast). She takes daily hydrocortisone, fludrocortisone and stress dose hydrocortisone as needed. Conclusion: In non-classic LACH, the onset is generally late or not acute. Initial clinical features are variable and nonspecific. For this reason, non-classic LCAH may be overlooked. Adrenal crisis is a life-threatening complication, and it is important that clinicians are aware of the clinical features of non-classic LCAH and consider it in the differential diagnoses. Genetic testing for STAR should be considered in individuals with non-autoimmune primary adrenocortical insufficiency.

Comprehensive and Cost-Effective Strategy for Genetic Screening of Congenital Adrenal Hyperplasia (CAH) in India

Background: With substantial challenges in molecular analysis of 21 hydroxylase deficiency and lack of studies in extended panel of genes implicated in CAH, genetic diagnosis is largely unavailable and unaffordable in India. Therefore, we aim to develop a cost-effective screening strategy in CAH using Allele Specific PCR and Targeted Next-Generation Sequencing (NGS). Methods: Long range PCR and restriction digestion were utilized to specifically amplify the CYP21A2 gene whereas multiplex PCR was used to amplify CYP11B1, CYP17A1, CYP19A1 and POR genes. In house developed Allele Specific PCR (ASPCR) for 8 hotspot mutations in CYP21A2 gene and targeted NGS for five genes was carried out. The results were validated using Sanger sequencing and MLPA. Results: Of the 50 patients suspected for 21 hydroxylase deficiency, 64% (n=32) were of Salt Wasting phenotype (SW), 30% (n=15) with Simple Virilizing (SV) phenotype and 6% (n=3) of the study population were suspected for non-classical (NC) CAH. The mutation positive rate of ASPCR was 86% (n=43). Seven patients carried more than two biallelic mutations indicating smaller gene conversions. The predominant mutation identified among the study subjects was I2G splice variant in SW phenotype (38%) and I172N in the SV phenotype (41%). Based on the Long range PCR amplification and restriction digestion we identified one patient with large gene conversion and one patient with large 30kb deletion. These results were confirmed with MLPA.Additionally, utilizing the Targeted NGS we identified five patients with CYP21A2 variants (two patients with novel variants c.1274G>T, c.17_18delTG and two other variants in three patients - c.1451G>C, c.143A>G). We also identified a CYP19A1:c.1142A>T gene variant in a patient who was initially suspected for 21 hydroxylase deficiency. Out of six patients with 11 beta hydroxylase deficiency four patients were positive for homozygous CYP11B1 variants (c.1201-1G>A, c.1200 + 1delG, c.412C>T) and two patients with compound heterozygous variants (c.1024C>T and c.1012dupC, c.623G>A and c.412C>T). Discussion: Utilizing the novel allele specific PCR followed by NGS we identified a total of 96% (48/50) of 21 hydroxylase deficiency patients with homozygous or compound heterozygous mutations and 2% (2/50) were positive for single heterozygous variant in CYP21A2 gene. ASPCR followed by multigene targeted NGS assay for genetic screening in CAH has shown to be a sensitive and specific strategy established in a clinical setting. To best of our knowledge this is the most cost-effective and comprehensive multigene screening carried out in India.

Exaggerated Premature Adrenarche in Boys: Comparative Study of a Therapeutic Intervention With the Aromatase Inhibitor Anastrozole Versus Morning Low Dose Hydrocortisone

Abstract Background: In boys, idiopathic premature adrenarche (IPA) is defined as the appearance of pubic or axillary hair/odor before the age of 9 yrs, not due to pathology of the adrenal glands. Exaggerated Adrenarche (EXAD), occurring in 10-15% of children with IPA, is characterized by an elevated &amp;gt;10 DHEA/Δ4 ratio (theoretically indicating reduced 3-β-HSD activity) and accelerated bone age (BA) maturation, continuously increasing the projecting distance from the target height (TH) curve, beyond the one observed in the pattern of Constitutional Advancement of Growth (CAG), eventually leading to short stature (SS). It is traditionally successfully treated with a morning (6-8 am) low dose of hydrocortisone (8 mg/m2) in order to reduce the androgens produced and delay BA progression, similarly to the standard treatment of non-classical (late-onset) CAH. Third generation aromatase inhibitors (AI) have been shown to delay BA by inhibiting the peripheral aromatization of androgens and are being widely used off-label to treat short SS in boys. Aims: To evaluate the effectiveness of the AI anastrozole in delaying BA in boys with EXAD. Methods: 39 boys with advanced BA and a predicted adult height (PAH) &amp;lt;170cm and &amp;gt; -1SDS from TH) were included. Group-A (n=28) received anastrozole 1mg x 1 p.o. and group-B (n=11) low dose (8 mg/m2) hydrocortisone at 6-8 am for at least 3 yrs. All measurements were made on the same height meter by the same examiner. The two groups did not differ in terms of age at intervention onset: 8.6 in group A vs 8.74 yrs in group B, TH: 175.7 vs 175.7 cm, PAH: 168.4 vs 167.8 cm and BA advancement: +2.3 yrs in group A vs +2.4 yrs in group B. A 6-month follow-up included clinical examination, BA assessment, and laboratory tests (general blood, lipid chart, LH, FSH, TESTO, E2, E1, and complete calcium metabolism). Lumbar spine DEXA scan and X-Ray was performed on an annual basis. Results: Both groups had a statistically significant gain in PAH after 3yrs of treatment: Group A +10.3 cm (1.53 SD), p&amp;lt;0.001, and group B +7.1 cm (1.06 SD), p=0.007. Thus, group A exceeded their TH by +3cm (0.45 SDS) and group B reached -0.8cm (-0.11 SDS) from their TH, p=0.03. The reduction of BA advancement was statistically significant in both groups (p&amp;lt;0.05), with superiority of the anastrozole-treated group: at 3yrs in group A BA advancement was +0.48 yrs, and at group B +1.24 yrs (p&amp;lt;0.001). No clinical adverse events or abnormal tests were noted in any of the groups. Bone density and vertebral morphology was not affected within or between groups. Conclusions: Aromatase Inhibitors may have a place in managing exaggerated adrenarche in boys, showing superiority to traditional low-dose hydrocortisone in improving predicted adult height and delaying bone age maturation, but notably by overcoming quality of life and compliance issues associated with hydrocortisone therapy (mandatory 6-8 am).