Phenotype Of Congenital Adrenal Hyperplasia Research Articles

Genotype-phenotype correlation and feminizing surgery in Danish children with congenital adrenal hyperplasia.

Congenital adrenal hyperplasia (CAH) is characterized by a broad spectrum of symptoms. This study aims to describe genotype-phenotype correlations, clinical manifestations at diagnosis, and the frequency of feminizing surgery in childhood. A nationwide retrospective cohort study of patients diagnosed with CAH, aged ≤18, between 1943 and 2018. CAH was identified in national registries and validated through medical record reviews and phenotypically classified as salt-wasting (SW), simple virilizing (SV), or non-classic (NC) CAH. In a sub-cohort (diagnosed between 1999 and 2018) clinical data and feminizing surgery data were investigated. CYP21A2 variants were grouped as Null, A, B, C, and D. The cohort comprised 379 patients with CAH. Genotype-phenotype correlations were as follows: Null and SW (100%), A and SW (94%), B and SV (51%), and C and NC (75%). In the subcohort (n=159, females=99) the female-to-male ratios were: SW=1.5, SV=1.1, and NC=2.3. Symptoms of precocious pseudopuberty dominated at diagnosis (39%). Males presented with significantly advanced bone age by the time of diagnosis (p=0.0009). In 53% of females (n=53), virilization of the external genitalia was present at the time of diagnosis, and in 46% (n=46) this developed already prenatally. Of the prenatal virilized females 85% underwent early feminizing genitoplasty. Virilization was identified in both mild and severe genotypes. Milder genotypes do not accurately predict CAH phenotype or prenatally reject serious outcomes such as virilization. The frequency of early genitoplasty is high among females with prenatal virilization. The delayed diagnosis and non-diagnosis of especially males with mild CAH advocate for a more prominent role of genetic testing in the diagnostic and screening for CAH.

7955 Increased occurrence of psychiatric disorders and use of psychiatric-related medication in patients with congenital adrenal hyperplasia

Abstract Disclosure: M. Lind-Holst: None. D. Hansen: None. K.M. Main: None. A. Juul: None. M. Andersen: None. M. Dunø: None. Å.K. Rasmussen: None. N. Jørgensen: None. C.H. Gravholt: None. A. Berglund: None. Background: Clinical studies on psychiatric morbidity, quality of life and cognition in patients with congenital adrenal hyperplasia (CAH) imply impaired mental health. Epidemiological studies on psychiatric morbidity in CAH are, however, scarce. Methods: A registry study of hospital diagnoses and prescribed medication related to psychiatric disorders in a national cohort of patients (n=462) diagnosed with CAH from 1943 to 2018 compared to 100 randomly selected sex- and age-matched controls (n=44,527) from the general population. Psychiatric hospital diagnoses were available for in-patient contacts from 1968 and out-patient contacts from 1994. Medication data were available from 1995. Outcomes: CAH was associated with an increased risk of hospital contacts related to any psychiatric diagnosis (incidence rate ratio (IRR)=2.73, 95% CI 1.85-4.04), and this applied to both males (IRR=2.48, 95% CI 1.57-3.91) and females (IRR=3.20, 95% CI 1.58-6.50). Psychiatric disorders due to psychoactive substance use were more common among CAH males (IRR=3.55, 95% CI 1.58-7.96) and females (IRR=3.81, 95% CI 1.71-8.48). Males with CAH also had an increased risk of suicidal behaviour (IRR=10.66, 95% CI 3.74-30.42). By the age of 30 years, 23% of CAH females and 21% of CAH males had at least one diagnosis related to a psychiatric disorder while this was the case in 14% of female controls and 15% of male controls. Stratifying by sex and CAH phenotype there were important differences among groups. Prescription of medication related to psychiatric disorders was increased for CAH overall (HR=1.73, 95% CI 1.48-2.03) and males (HR=1.80, 95% CI 1.35-2.38) and females (HR=1.70, 95% CI1.36-2.38), separately. Age at the first prescription of any psychiatry-related medication was significantly earlier for patients than for controls (HR males=1.67, 95% CI 1.2-2.3; HR females=1.48, 95% CI 1.2-1.8). Thirty-five per cent (157/448) of CAH patients and 24% of controls had at least one prescription related to a psychiatric disorder within the study period. Interpretation: An increased risk of psychiatric morbidity, psychoactive substance use and use of medication related to poor mental health was seen in both males and females with CAH. The risk of suicidal behaviour was increased for patients with CAH, yet only significantly in CAH males. The study underlines the need for more attention and extension of psychological care and support for patients with CAH. Presentation: 6/1/2024

7955 Increased occurrence of psychiatric disorders and use of psychiatric-related medication in patients with congenital adrenal hyperplasia

Abstract Disclosure: M. Lind-Holst: None. D. Hansen: None. K.M. Main: None. A. Juul: None. M. Andersen: None. M. Dunø: None. Å.K. Rasmussen: None. N. Jørgensen: None. C.H. Gravholt: None. A. Berglund: None. Background: Clinical studies on psychiatric morbidity, quality of life and cognition in patients with congenital adrenal hyperplasia (CAH) imply impaired mental health. Epidemiological studies on psychiatric morbidity in CAH are, however, scarce. Methods: A registry study of hospital diagnoses and prescribed medication related to psychiatric disorders in a national cohort of patients (n=462) diagnosed with CAH from 1943 to 2018 compared to 100 randomly selected sex- and age-matched controls (n=44,527) from the general population. Psychiatric hospital diagnoses were available for in-patient contacts from 1968 and out-patient contacts from 1994. Medication data were available from 1995. Outcomes: CAH was associated with an increased risk of hospital contacts related to any psychiatric diagnosis (incidence rate ratio (IRR)=2.73, 95% CI 1.85-4.04), and this applied to both males (IRR=2.48, 95% CI 1.57-3.91) and females (IRR=3.20, 95% CI 1.58-6.50). Psychiatric disorders due to psychoactive substance use were more common among CAH males (IRR=3.55, 95% CI 1.58-7.96) and females (IRR=3.81, 95% CI 1.71-8.48). Males with CAH also had an increased risk of suicidal behaviour (IRR=10.66, 95% CI 3.74-30.42). By the age of 30 years, 23% of CAH females and 21% of CAH males had at least one diagnosis related to a psychiatric disorder while this was the case in 14% of female controls and 15% of male controls. Stratifying by sex and CAH phenotype there were important differences among groups. Prescription of medication related to psychiatric disorders was increased for CAH overall (HR=1.73, 95% CI 1.48-2.03) and males (HR=1.80, 95% CI 1.35-2.38) and females (HR=1.70, 95% CI1.36-2.38), separately. Age at the first prescription of any psychiatry-related medication was significantly earlier for patients than for controls (HR males=1.67, 95% CI 1.2-2.3; HR females=1.48, 95% CI 1.2-1.8). Thirty-five per cent (157/448) of CAH patients and 24% of controls had at least one prescription related to a psychiatric disorder within the study period. Interpretation: An increased risk of psychiatric morbidity, psychoactive substance use and use of medication related to poor mental health was seen in both males and females with CAH. The risk of suicidal behaviour was increased for patients with CAH, yet only significantly in CAH males. The study underlines the need for more attention and extension of psychological care and support for patients with CAH. Presentation: 6/1/2024

Temporal Trends in Acute Adrenal Insufficiency Events in Children With Congenital Adrenal Hyperplasia During 2019-2022.

It is unclear whether targeted monitoring of acute adrenal insufficiency (AI) related adverse events (AE) such as sick day episodes (SDEs) and hospitalization rate in congenital adrenal hyperplasia (CAH) is associated with a change in the occurrence of these events. Study temporal trends of AI related AE in the I-CAH Registry. In 2022, data on the occurrence of AI-related AE in children aged <18 years with 21-hydroxylase deficiency CAH were compared to data collected in 2019. In 2022, a total of 513 children from 38 centers in 21 countries with a median of 8 children (range 1-58) per center had 2470 visits evaluated over a 3-year period (2019-2022). The median SDE per patient year in 2022 was 0 (0-2.5) compared to 0.3 (0-6) in 2019 (P = .01). Despite adjustment for age, CAH phenotype and duration of study period, a difference in SDE rate was still apparent between the 2 cohorts. Of the 38 centers in the 2022 cohort, 21 had also participated in 2019 and a reduction in SDE rate was noted in 13 (62%), an increase was noted in 3 (14%), and in 5 (24%) the rate remained the same. Of the 474 SDEs reported in the 2022 cohort, 103 (22%) led to hospitalization compared to 299 of 1099 SDEs (27%) in the 2019 cohort (P = .02). The I-CAH Registry can be used for targeted monitoring of important clinical benchmarks in CAH. However, changes in reported benchmarks need careful interpretation and longer-term monitoring.

Impact of Newborn Screening on Adult Height in Patients with Congenital Adrenal Hyperplasia (CAH).

Treatment of children with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is challenging. Linear growth and adult height are compromised according to recent publications. However, most of these data were obtained in the era before CAH newborn screening. Body height of patients with classical CAH diagnosed before and after the establishment of newborn screening were analyzed retrospectively. We identified 600 patients with classical CAH (227 male) with data on near-adult height (NAH), target height (TH), and information on newborn screening from the electronic German CAH registry (DGPAED society). Newborn screening was performed in 101 (16.8%) patients. All patients received hydrocortisone with or without fludrocortisone.To assess the effects of newborn screening, a linear regression model adjusted/stratified for sex and phenotype was used (SAS 9.4). TH corrected NAH (mean; 95% confidence interval) was closer to zero in patients with CAH and newborn screening (-0.25 SDS; -0.44 - -0.06) than in patients without newborn screening (-0.44 SDS; -0.52 - -0.36) (p=0.069). Screening had no effect on NAH in female patients. In male patients, NAH was significantly better (p=0.033) with screening than without screening. After stratifying for CAH phenotype, screening did not affect the NAH of patients with Salt-wasting-CAH. Patients with Simple-virilizing-CAH had a significantly better cNAH (p=0.034) with screening (0.15 SDS; -0.28 - 0.59) than without screening (-0.35 SDS; -0.52 - -0.18). Our data suggest that newborn screening might be associated with improved near-adult height in male CAH patients and in patients with SV-CAH.

SUN-204 Case of Non-Classic Congenital Adrenal Hyperplasia with Compound CYP21A2 Mutations Combined with CYP11B1 Mutation

Introduction:Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder, caused by a deficiency in one of the enzymes involved in adrenal steroid synthesis. Homozygotes usually have a severe classical CAH phenotype. Heterozygotes, carrying only one abnormal copy of the gene, are thought to be generally asymptomatic, although could be associated with hyperandrogenism, decreased fertility, adrenal incidentalomas.21-hydroxylase deficiency (21OHD) accounts for 90% of all CAH cases, while 11 β-hydroxylase deficiency (11OHD) accounts for 4–8% of CAH cases.The nature and mechanism of a combined enzymatic defect are unknown. The coincidental presence of gene mutation for both 21OHD and 11OHD CAH in a single individual is very unlikely to occur.Clinical case:A 22-year old female with no significant past medical history presented to endocrinologist for evaluation of facial hirsutism.Patient had menarche at age 11, and menstrual cycle was regular since. No concerns for virilization of external genitalia. She was not sexually active, no pregnancies. No Family history of infertility or genetic conditions. Patient’s father was Jewish, and mother was Slavic.Physical examination revealed female phenotype, normal Blood pressure and BMI, acne on the back and upper arm, Ferriman-Gallwey hirsutism score 5. Labs: AM cortisol, CMP, CBC and TSH were normal. Total testosterone 68 ng/dL (2–45), free testosterone 7 pg/mL (0.1 - 6.4), FSH 5.7 mIU/mL (2.5–10.2), LH 10.6 mIU/mL (1.9–12.5), Progesterone 2.1 ng/mL (<1), Estradiol 51 pg/mL (19–144), 17-OH Progesterone 6728 ng/dL (45–285), Androstenedione 710 ng/dL (35–250), DHEA 1216 ng/dL (102 - 1185), 11-Deoxycortisol 204 ng/dL (<107), Pregnenolone 661 ng/dL(22–237), DHEAS 435 ng/dL (18–391).Elevated 11-Deoxycortisol level raised a suspicion for 11-OHD CAH, or adrenal vs ovarian hormone-producing mass.Abdominal CT and pelvic US were negative for adrenal or ovarian masses.3-day dexamethasone suppression test completely normalized all biochemical abnormalities the patient had.Genetic testing showed: CYP21A2 c.844G>T (non-classic 21OHD CAH mutation), CYP21A2 c.923dupT (classic 21OHD CAH mutation), CYP11B1 c.953C>G mutation.Thus diagnosis of non-classic 21OHD CAH, and carrier status of 11OHD CAH was made. She was started on oral Dexamethasone 0.25 mg every other day.11-Deoxycortisol elevation could not be explained by 21OHD alone. Her carrier state of the CYP11B1 mutation also cannot cause elevated 11-Deoxycortisol level.We hypothesize that 11-Deoxycortisol was elevated either from extra adrenal conversion of 17-hydroprogesterone to 11-Deoxycortisol, or from 11 β-hydroxylase inhibition by excess intra-adrenal androgens. Conclusion: Our case reports a rare finding of both CYP21A2 and CYP11B1 mutations in the same individual, which has implications for relatives, family planning and partner genetic screening.

Selective LC-MRM/SIM-MS based profiling of adrenal steroids reveals metabolic signatures of 17α-hydroxylase deficiency

Adrenal steroids are generated in the adrenal cortex and metabolized by various enzymes such as hydroxylases, dehydrogenases, and reductases. Determining the comprehensive metabolic signatures of adrenal steroids can provide insight into their metabolic functions and roles in the pathophysiology of adrenal diseases, including Cushing’s syndrome (CS) and congenital adrenal hyperplasia (CAH). To this end, we developed an advanced quantitative profiling method of serum adrenal steroids with liquid chromatography-mass spectrometry (LC–MS) under molecular-specific scan modes. Twenty-seven steroids were separated on a 1.9-μm particle C18 column (50 × 2.1 mm) at a flow rate of 250 μL/min and quantified via triple-quadrupole MS with electrospray ionization. During validation, linearities ( r2) were higher than 0.940 with a limit of quantification of 0.1–5.0 ng/mL, and precision (coefficient of variation) and accuracy (%bias) of 3.7–14.3 % and 96.3–113.1 %, respectively. In contrast with the significantly increased serum levels of mineralocorticoids (P < 0.001), the present LC–MS assay revealed remarkably decreased levels of all glucocorticoids and androgens in a patient diagnosed with 17α-hydroxylase deficiency CAH (P < 0.001) compared to those of age- and sex-matched healthy and CS subjects. In the CAH patient, the metabolic ratios for 17α-hydroxylase were significantly decreased, whereas there was no reduction in the metabolic ratio of 17-hydroxyprogesterone to androstenedione, indicating 17,20-lyase activity. In particular, both pregnenolone and dehydroepiandrosterone sulfates, and their metabolic ratio, were identified as potential biomarkers for 17α-hydroxylase deficiency (all P < 0.001), which were also distinct from those of CS patients. The devised LC–MS assay clearly revealed the metabolic signatures of 17α-hydroxylase deficiency, as a rare phenotype of CAH, compared to both healthy and CS subjects, indicating its utility for screening adrenal diseases.

Genotype/phenotype correlations in 538 congenital adrenal hyperplasia patients from Germany and Austria: discordances in milder genotypes and in screened versus prescreening patients.

Congenital adrenal hyperplasia (CAH) due to CYP21A2 gene mutations is associated with a variety of clinical phenotypes (salt wasting, SW; simple virilizing, SV; nonclassical, NC) depending on residual 21-hydroxylase activity. Phenotypes and genotypes correlate well in 80–90% of cases. We set out to test the predictive value of CAH phenotype assignment based on genotype classification in a large multicenter cohort. A retrospective evaluation of genetic data from 538 CAH patients (195 screened) collected from 28 tertiary centers as part of a German quality control program was performed. Genotypes were classified according to residual 21-hydroxylase activity (null, A, B, C) and assigned clinical phenotypes correlated with predicted phenotypes, including analysis of Prader stages. Ultimately, concordance of genotypes with clinical phenotypes was compared in patients diagnosed before or after the introduction of nationwide CAH-newborn screening. Severe genotypes (null and A) correlated well with the expected phenotype (SW in 97 and 91%, respectively), whereas less severe genotypes (B and C) correlated poorly (SV in 45% and NC in 57%, respectively). This was underlined by a high degree of virilization in girls with C genotypes (Prader stage >1 in 28%). SW was diagnosed in 90% of screening-positive babies with classical CAH compared with 74% of prescreening patients. In our CAH series, assigned phenotypes were more severe than expected in milder genotypes and in screened vs prescreening patients. Diagnostic discrimination between phenotypes based on genotypes may prove overcome due to the overlap in their clinical presentations.

ID: 1048 A novel nonsense mutation in the CYP21A2 gene of a Vietnamese patient with congenital adrenal hyperplasia

Inactivating mutations in the CYP21A2 gene which encodes the protein involved in steroid synthesis have been reported in the patients with congenital adrenal hyperplasia (CAH). An infant who diagnosed with the severe phenotype of CAH such as increasing testicular volume, elevating of 17-hydroxyprogesteron, testosterone and progesterone and his family were subjected for genetic studies. Initially, we used PCR and direct sequencing to screen mutations in the CYP21 gene in the proband and his family. We identified a novel nonsense mutation c.374C&gt;G predicts a substitution of serine for a stop codon at codon 125 (p.S125*) within exon 3 in the proband. However, the inheritance pattern of the mutation was not consistent with disease causation because of a heterozygous mutation carrier in father and sibling, wild-type alleles in mother but mutant alleles in proband. This inspired us to find deletions of exon using multiplex ligation-dependent probe amplification (MLPA) assay. In the profiles of MLPA electropherogram, the proband had a large deletion in exon 3, but his mother did not have. It means that the proband inherited a normal allele from his mother and a mutant allele from his father, but the deletion of a normal allele occurred in the proband. Therefore, mutation c.374C&gt;G (p.S125*) in exon 3 in the proband is considered as a heterozygous deletion mutation. In addition, a large deletion in exon 1 in the maternal allele in the proband is observed. Taking together, the proband carried a nonsense mutation accompanied with two deletions in exon 1 and exon 3 in the CYP21A2 gene affect the CAH phenotype severity. These mutations also expand the CYP21A2 mutation spectrum in CAH disorder. This case also highlights the need of caution when interpreting results of molecular genetics and biochemical testing during genetic counseling.

Phenotypic, metabolic, and molecular genetic characterization of six patients with congenital adrenal hyperplasia caused by novel mutations in the CYP11B1 gene

Congenital adrenal hyperplasia (CAH) is an autosomal recessive inherited disorder of steroidogenesis. Steroid 11β-hydroxylase deficiency (11β-OHD) due to mutations in the CYP11B1 gene is the second most common form of CAH.In this study, 6 patients suffering from CAH were diagnosed with 11β-OHD using urinary GC–MS steroid metabolomics analysis. The molecular basis of the disorder was investigated by molecular genetic analysis of the CYP11B1 gene, functional characterization of splicing and missense mutations, and analysis of the missense mutations in a computer model of CYP11B1.All patients presented with abnormal clinical signs of hyperandrogenism. Their urinary steroid metabolomes were characterized by excessive excretion rates of metabolites of 11-deoxycortisol as well as metabolites of 11-deoxycorticosterone, and allowed definite diagnosis. Patient 1 carries compound heterozygous mutations consisting of a novel nonsense mutation p.Q102X (c.304C>T) in exon 2 and the known missense mutation p.T318R (c.953C>G) in exon 5. Two siblings (patient 2 and 3) were compound heterozygous carriers of a known splicing mutation c.1200+1G>A in intron 7 and a known missense mutation p.R448H (c.1343G>A) in exon 8. Minigene experiments demonstrated that the c.1200+1G>A mutation caused abnormal pre-mRNA splicing (intron retention). Two further siblings (patient 4 and 5) were compound heterozygous carriers of a novel missense mutation p.R332G (c.994C>G) in exon 6 and the known missense mutation p.R448H (c.1343G>A) in exon 8. A CYP11B1 activity study in COS-1 cells showed that only 11% of the enzyme activity remained in the variant p.R332G. Patient 6 carried a so far not described homozygous deletion g.2470_5320del of 2850bp corresponding to a loss of the CYP11B1 exons 3–8. The breakpoints of the deletion are embedded into two typical 6 base pair repeats (GCTTCT) upstream and downstream of the gene.Experiments analyzing the influence of mutations on splicing and on enzyme function were applied as complementary procedures to genotyping and provided a rational basis for understanding the clinical phenotype of CAH.

Prevalence of mutations nt656g and V281L in indigenous children of Russian Far North

Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders which is most often caused by deficiency of steroid 21-hydroxylase (CYP-21). High level of inbreeding in the populations of indigenous people of Russian Far North was the reason to assess the prevalence of CYP21-inactivating mutations nt656g (classical sodium wasting phenotype of CAH) and V281L (non-classical CAH) and the genotype-phenotype relationship in children-inhabitants of Yakutia and Yamal-Nenets Autonomous Region (YNAR). We examined children living in 9 settlements of Yakutia and in 4 settlements of YNAR: 65 Russians, 206 Sakha, 344 Evens, 88 Evenks, 34 Yukagirs, 7 Chukchi, 99 Dolgans, 41 Nenets, 137 Selkups, 21 others. Blood samples were drawn from 315 children living in Yakutia and from 176 children living in YNAR. Allele specific PCR was used (primers In2ns, In2ms, In2cs for mutation in intron 2 (656) A/C → G and primer Ex7ma for mutation in exon 7 (V281L)) with positive control DNA. In cases of positive reaction the procedure was repeated and if it was again positive sequencing was performed. We didn’t find homozygotes. Twelve heterozygotes have been revealed with mutations at CYP21 gene. Of them splicing mutation in intron 2 (nucleotide 656) was revealed on 1 chromosome, mutation in exon 7 (V281L) - on 11 chromosomes. Prevalence of mutation nt656g in Evens was 1:41 (2,4 : 100). In other ethnic groups it was not revealed. Hence on average for the whole studied group of children the prevalence of mutation nt656g was 0,4 : 100. The prevalence of mutation V281L was the highest in Chukchi (5,1 : 100) and Yukagirs (5 : 100) with average prevalence for the whole studied group 2,4 : 100. The prevalence of heterozygotes for the V281L mutation in whole studied group was found to be almost similar to the prevalence of heterozygotes for non-classical CAH in non-Ashkenazi population (1 : 60, Speiser P.W. et al., 1985). In Nenets and Selkup children living in YNAR the prevalence was half as high as the average for Native children in Yakutia.

Novel homozygous p.Y395X mutation in the CYP11B1 gene found in a Vietnamese patient with 11β-hydroxylase deficiency

ContextThe deficiency of steroid 11β-hydroxylase is caused by mutations in the CYP11B1 gene and is the second major form of congenital adrenal hyperplasia associated with hypertension. ObjectiveThe objective of this study was to screen the CYP11B1 gene for mutations in one Vietnamese male suffering from congenital adrenal hyperplasia. PatientThe patient (46,XY) had congenital adrenal hyperplasia. The clinical manifestations presented precocious puberty, hyper-pigmentation and high blood pressure at 4years. ResultsThe patient was a homozygous carrier of a novel mutation located in exon 7 containing a premature stop codon instead of tyrosine at 395 (p.Y395X). ConclusionWe have identified a novel mutant of the CYP11B1 gene in one Vietnamese family associated with phenotypes of congenital adrenal hyperplasia. The mutant gene p.Y395X produces a truncated form of the polypeptide and abolishes the enzyme activities, leading to a severe phenotype of congenital adrenal hyperplasia.

17α-hydroxlyase/17, 20-lyase Deficiency in Three Siblings with Primary Amenorrhea and Absence of Secondary Sexual Development

Background17α-hydroxlyase/17, 20-lyase deficiency (17OHD) is a rare phenotype of congenital adrenal hyperplasia that can cause primary amenorrhea. CaseThree phenotypically female siblings visited the adolescent gynecologic clinic complaining of primary amenorrhea and absence of secondary sexual developments. All had constant high blood pressure and showed a hypergonadotropic hypogonadal state with high progesterone and low testosterone levels. Two were genotypically females and one was genotypically a male; all were confirmed to have 17OHD, and estrogen replacement, glucocorticoids, and antihypertensive drugs were Prescribed to the patients. Summary and ConclusionIdentifying a 17OHD patient complaining of primary amenorrhea in a gynecologic clinic is important for proper management.

Identification and functional characterization of a novel mutation P459H and a rare mutation R483W in the CYP21A2 gene in two Chinese patients with simple virilizing form of congenital adrenal hyperplasia.

Steroid 21-hydroxylase deficiency (21-OHD) is the most common cause of congenital adrenal hyperplasia (CAH). Clinically, 21-OHD is categorized into saltwasting, simple-virilizing (SV), and non-classical (NC) forms. It is well recognized that a good correlation exists between genotype and clinical phenotype of CAH. The aim of this study was to identify CYP21A2 gene mutations in 2 Chinese patients with SV CAH along with their parents and other family members. By direct sequencing the CYP21A2 gene, a novel mutation, P459H, was detected in 1 patient; and a previously described uncharacterized mutation, R483W, was found in another patient. The 21-hydroxylase activities were determined by measuring the converting rate of progesterone to 11-deoxycorticosterone in COS-7 cells overexpressed with these mutated proteins. Our results revealed significantly reduced enzyme activity in both mutants: residual activity of P459H and R483W towards progesterone was 6.8%±2.1 and 2.9%±1.5, respectively compared to that of the wild type. We also demonstrated the loss of 21-hydroxylase activities using a three-dimensional model of CYP21A2. Both R483W and P459H mutations are confirmed to be related to NC CAH by in vitro functional study, with phenotype variance of R483W in Tunisian and Chinese patients. This study will aid in predicting disease severity and in facilitating family genetic counseling.

Novel Mutations inCYP11B1Gene Leading to 11β-Hydroxylase Deficiency in Brazilian Patients

Deficiency of 11 beta-hydroxylase results in the impairment of the last step of cortisol synthesis. In females, the phenotype of this disorder includes different degrees of genital ambiguity and arterial hypertension. Mutations in the CYP11B1 gene are responsible for this disease.The objective of the study was to screen the CYP11B1 gene for mutations in two unrelated Brazilian females with congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency.The coding and intron-exon junction regions of CYP11B1 were totally sequenced. A putative splice mutation was further investigated by minigene transcription.We report two novel CYP11B1 mutations in these Brazilian patients. An Arabian Lebanese descendent female was found to be homozygous for a cytosine insertion at the beginning of exon 8, changing the 404 arginine to proline. It alters the open reading frame, creating a putative truncated protein at 421 residue, which eliminates the domain necessary for the association of heme prosthetic group. A severely virilized female was homozygous for the g.2791G>A transition in the last position of exon 4. This nucleotide is also part of 5' intron 4 donor splice site consensus sequence. Minigene experiments demonstrated that g.2791G>A activated an alternative splice site within exon 4, leading to a 45-bp deletion in the transcript. The putative translation of such modified mRNA indicates a truncated protein at residue 280.We describe two novel mutations, g.4671_4672insC and g.2791G>A, that drastically affects normal protein structure. These mutations abolish normal enzyme activity, leading to a severe phenotype of congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency.

Rare mutations in the CYP21A2 gene detected in congenital adrenal hyperplasia

Objectives The purpose of this study was to identify and determine the frequencies of rare CYP21A2 gene mutations in patients with 21-hydroxylase deficiency (21-OHD) in the Cypriot population. Design and methods Direct sequencing and MLPA analysis of the CYP21A2 gene. Results A group of families with 21-OHD were screened for the presence of rare CYP21A2 gene mutations. The rare V304M missense mutation was detected as compound heterozygous in two females with the nonclassical (NC) form of congenital adrenal hyperplasia (CAH). The rare F306insT was also detected in a female with severe salt wasting in the homozygous state and in cis in both alleles with the V281L mutation. Lastly, the rare A391T missense mutation was reported in a female patient with NC-CAH. A carrier rate of 2.1% for the V304M was also observed in a cohort of healthy controls. Conclusions The frequency of V304M mutation among Cypriots is high and the first reported so far and patients characterized as compound heterozygotes or heterozygotes are most readily identified by a mild phenotype of CAH. Thus, V304M should be included in the panel of mutations associated with the NC forms of 21-OHD.

Six Cases of Congenital Adrenal Hyperplasia That Were Due to 17α-hydroxylase/17,20-lyase Deficiency

α-hydroxylase/17,20-lyase deficiency is a rare phenotype of congenital adrenal hyperplasia (CAH), and this is characterized by hyporeninemic hypertension, primary amenorrhea and abnormality of the secondary sexual characteristics (pseudohermaphroditism in men). This typ e of CAH is usually misdiagnosed at first as mineralocorticoid induced hypertension with primary aldosteroni sm, but primary amenorrhea with deficient sex hormone is a clue for making the correct diagnosis. The authors experienced 6 cases of 17α -hydroxylase/17,20-lyase deficiency in patients who ranged from 15 to 42 years of age. 4 cases were diagnosed according to the investigation of their mineralocorticoid-induced hypertension and 2 cases their primary amenorrhea and sexual infantilism. All of them had hypokalemia, hyporeninemic hypertension and an atrophied uterus and ovaries. In the genotypic male (46 XY), the testicles were atrophied in the abdominal cavity. The levels of cortisol, estrogen and dehydroepiandroste rone sulfate (DHEAS) were low, but the levels of progesterone and 11-deoxycorticosterone were high. Therefore, the diagnosis of 17α-hydroxylase/17,20-lyase deficiency should be considered in female patients who present with both sexual infantilism and mineralocorticoid hypertension. We report on these cases with a brief review of the literature. (J Korean

Divergent Phenotype of Two Siblings Human Leukocyte Antigen Identical, Affected by Nonclassical and Classical Congenital Adrenal Hyperplasia Caused by 21-Hydroxylase Deficiency

Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders most often caused by enzyme 21-hydroxylase deficiency. Most mutations causing enzymatic deficiency are generated by recombinations between the active gene CYP21 and the pseudogene CYP21P. Only 1-2% of affected alleles result from spontaneous mutations. The phenotype of CAH varies greatly, usually classified as classical or nonclassical, depending on variable degree in 21-hydroxylase activity. Here we report a divergent phenotype of two human leukocyte antigen identical siblings, affected by nonclassical and classical CAH caused by 21-hydroxylase deficiency due to different genotype. Using direct sequencing method and Southern blot, we studied two children (one male and one female), affected, respectively, by nonclassical and classical CAH and their parents. The mother was heterozygous for the Q318X mutation, and the father was heterozygous for the V281L mutation. The brother was a compound heterozygote for the mutations V281L and Q318X, whereas the proband was compound heterozygote for the Q318X mutation and a large conversion. The two children are human leukocyte antigen identical (A*02;B*14;DRB1*01/A*33;B*14;DRB1*03). Different phenotype of the proband is the result of compound heterozygosity for the maternal mutation Q318X and a de novo large conversion.

Non-Classical Congenital Adrenal Hyperplasia Phenotype in a Female Newborn Heterozygous for the 21-Hydroxylase Gene Mutation

Non-Classical Congenital Adrenal Hyperplasia Phenotype in a Female Newborn Heterozygous for the 21-Hydroxylase Gene Mutation