Ariachery C. Ammini

Phenotypical, Biological, and Molecular Heterogeneity of 5α-Reductase Deficiency: An Extensive International Experience of 55 Patients

CONTEXT In 46,XY disorders of sex development, 5α-reductase deficiency is rare and is not usually the first-intention diagnosis in newborn ambiguous genitalia, contrary to partial androgen insensitivity syndrome. Yet the cause of ambiguous genitalia may guide sex assignment, and rapid, precise diagnosis of 5α-reductase deficiency is essential. OBJECTIVE The aim of the study was to describe relevant data for clinical diagnosis, biological investigation, and molecular determination from 55 patients with srd5A2 mutations identified in our laboratory over 20 yr to improve early diagnosis. SETTING The study was performed at Montpellier University Hospital. PATIENTS We studied a cohort of 55 patients with srd5A2 gene mutations. MAIN OUTCOME MEASURE(S) Genetic analysis of srd5A2 was conducted. RESULTS Clitoromegaly (49.1%) and microphallus with various degrees of hypospadias (32.7%) were frequent phenotypes. Female external genitalia (7.3%) and isolated micropenis (3.6%) were rare. Seventy-two percent of patients were initially assigned to female gender; five of them (12.5%) switched to male sex in peripuberty. Over 72% of patients were considered for 5α-reductase deficiency diagnosis when the testosterone/dihydrotestosterone cutoff was 10. In 55 patients (with 20 having a history of consanguinity), we identified 33 different mutations. Five have never been reported: p.G32S, p.Y91H, p.G104E, p.F223S, and c.461delT. Homozygous mutations were present in 69.1% of cases, compound heterozygous mutations in 25.5%, and compound heterozygous mutations alone with the V89L polymorphism in 5.4%. Exons 1 and 4 were most affected, with 35.8 and 21.7% mutant alleles per exon, respectively. CONCLUSIONS In the largest cohort to date, we demonstrate a wide spectrum of phenotypes and biological profiles in patients with 5α-reductase deficiency, whatever their geographical or ethnic origins.

Mutations within the transcription factor PROP1 are rare in a cohort of patients with sporadic combined pituitary hormone deficiency (CPHD).

Objective  Mutations within the pituitary‐specific paired‐like homeobox gene PROP1 have been described in 50–100% of patients with familial combined pituitary hormone deficiency (CPHD). We screened a cohort of sporadic (n = 189) and familial (n = 44) patients with hypopituitarism (153 CPHD and 80 isolated hormone deficiencies) for mutations within the coding sequence of PROP1.

Negative correlation between negative symptoms of schizophrenia and testosterone levels.

Abstract: We conducted a pilot study in 10 adult male schizophrenics, 5 with predominantly positive symptoms (group I) and 5 with predominantly negative symptoms (group II), and 10 healthy matched controls. No significant differences in serum levels of testosterone (T), dehydroepiandrosterone sulfate (DHEAS), estradiol, and cortisol were found between patients as a whole and controls, using radioimmunoassay. However, serum T and DHEAS levels were lower (P <0.05) in group II patients than in group I. Body hair and aggression scores also were lower (P <0.05) in group II. In a much larger sample, Shirayama and colleagues also showed that “moderate negative symptoms, but not low negative symptoms” correlated negatively with T (P <0.05), but positively with ACTH (P <0.05) and cortisol (P <0.01) levels in plasma. Neuroactive steroids, such as DHEAS, and other sex hormones, including their synthetic derivatives, may have an adjunctive role in reversing or slowing the progression of negative symptoms. Indeed, “DHEA augmentation” improved “negative (P <0.01), depressive (P <0.05), and anxiety (P <0.01) symptoms.“

Chronic renal insufficiency among Asian Indians with type 2 diabetes: I. Role of RAAS gene polymorphisms

BackgroundRenal failure in diabetes is mediated by multiple pathways. Experimental and clinical evidences suggest that renin-angiotensin-aldosterone system (RAAS) has a crucial role in diabetic kidney disease. A relationship between the RAAS genotypes and chronic renal insufficiency (CRI) among type 2 diabetes subjects has therefore been speculated. We investigated the contribution of selected RAAS gene polymorphisms to CRI among type 2 diabetic Asian Indian subjects.MethodsTwelve single nucleotide polymorphisms (SNPs) from six genes namely-renin (REN), angiotensinogen (ATG), angiotensin converting enzyme I (ACE), angiotensin II type 1 receptor (AT1) and aldosterone synthase (CYP11B2) gene from the RAAS pathway and one from chymase pathway were genotyped using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method and tested for their association with diabetic CRI using a case-control approach. Successive cases presenting to study centres with type 2 diabetes of ≥2 years duration and moderate CRI diagnosed by serum creatinine ≥3 mg/dl after exclusion of non-diabetic causes of CRI (n = 196) were compared with diabetes subjects with no evidence of renal disease (n = 225). Logistic regression analysis was carried out to correlate various clinical parameters with genotypes, and to study pair wise interactions between SNPs of different genes.ResultsOf the 12 SNPs genotyped, Glu53Stop in AGT and A>T (-777) in AT1 genes, were monomorphic and not included for further analysis. We observed a highly significant association of Met235Thr SNP in angiotensinogen gene with CRI (O.R. 2.68, 95%CI: 2.01–3.57 for Thr allele, O.R. 2.94, 95%CI: 1.88–4.59 for Thr/Thr genotype and O.R. 2.68, 95%CI: 1.97–3.64 for ACC haplotype). A significant allelic and genotypic association of T>C (-344) SNP in aldosterone synthase gene (O.R. 1.57, 95%CI: 1.16–2.14 and O.R. 1.81, 95%CI: 1.21–2.71 respectively), and genotypic association of GA genotype of G>A (-1903) in chymase gene (O.R. 2.06, 95%CI: 1.34–3.17) were also observed.ConclusionSNPs Met235Thr in angiotensinogen, T>C (-344) in aldosterone synthase, and G>A (-1903) in chymase genes are significantly associated with diabetic chronic renal insufficiency in Indian patients and warrant replication in larger sample sets. Use of such markers for prediction of susceptibility to diabetes specific renal disease in the ethnically Indian population appears promising.

Effect of oral contraceptive containing ethinyl estradiol combined with drospirenone vs. desogestrel on clinical and biochemical parameters in patients with polycystic ovary syndrome.

BACKGROUND A prospective randomized trial was conducted to compare efficacy of a drospirenone-containing combined oral contraceptives (COC) with desogestrel-containing COC in women with polycystic ovary-syndrome (PCOS) not desirous of child-bearing. STUDY DESIGN Sixty women were randomized into study group [ethinylestradiol (EE) 30 mcg+drospirenone 3 mg] and control group (EE 30 mcg+desogestrel 150 mcg), treated for 6 months and followed up at 1 month, 3 months, 6 months, during treatment and 3 and 6 months post-treatment. Acne and hirsutism scoring, bodyweight, body mass index (BMI), blood pressure (BP), ultrasound parameters, lipid profile, glycemic profile and hormonal profile were compared. RESULTS Cycles were regular in both groups during treatment. Effect of regular cycles persisted in 44.83% (13/30) vs. 17.24% (5/30) in study vs. control group at 6 months post-treatment with 33.3% decreased hirsutism score in the study group (versus no change in control group) even at 6 months after stopping treatment. With treatment, BMI fell by 0.52 kg/m(2) in the study group; systolic and diastolic BP fell in the study group while it rose in the control group. Low-density lipoprotein significantly decreased and high-density lipoprotein was elevated in the study group (p<.05). The study group showed a significant fall in fasting/postprandial blood sugar and insulin and total testosterone against a rise in the control group. CONCLUSION In women with PCOS, a drospirenone containing COC has better outcome in terms of persistent regular cycles, antiandrogenic effect, fall in BMI and BP, better lipid profile, favorable glycemic and hormonal profile than desogestrel-containing COC.

⁶⁸Ga-DOTANOC PET/CT in patients with carcinoma of unknown primary of neuroendocrine origin.

Objective: To evaluate the role of 68Ga-DOTANOC (68Gallium-labeled [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-NaI3-octreotide) PET/CT for localization of the primary tumor in patients with carcinoma of unknown primary of neuroendocrine origin. Material and Methods: Twenty patients (median age, 55 years; male 10) with histopathologically proven metastatic neuroendocrine tumor and no localization of primary tumor on conventional imaging were included in the study. PET/CT was done after injection of 132–222 MBq (4–6 mCi) of 68Ga-DOTANOC. Images were evaluated by 2 experienced nuclear medicine physicians both qualitatively as well as quantitatively (maximum standardized uptake value). Histopathology (when available) and/or follow-up imaging with biochemical markers were taken as reference standard. Results: 68Ga-DOTANOC PET/CT localized the primary tumor in 12/20 (60%) patients. Midgut was the most common site of primary tumor (n = 9); duodenum (4), ileum (4), and colon (1). In 1 patient each the primary was localized to the pancreas, stomach, and lung. In these 12 patients, significant correlation was found between maximum standardized uptake value of primary tumor and metastasis (&rgr; = 0.615; P = 0.041). Even in patients in whom no primary tumor was localized, additional sites of metastatic disease were observed when compared with conventional imaging, mostly in lymph nodes and bones. There was a change in management in 3/20 patients (15%), who underwent surgery. In the remaining 17 patients, demonstration of somatostatin receptor expression by PET/CT made them suitable candidate for peptide receptor radionuclide therapy. Conclusion: 68Ga-DOTANOC PET/CT seems to be a promising modality for detecting primary tumor in patients with carcinoma of unknown primary of neuroendocrine origin.

Etiology, clinical profile, gender identity and long-term follow up of patients with ambiguous genitalia in India.

There is little information on the profile of children with ambiguous genitalia in India. Presented here is an analysis of patients with ambiguous genitalia registered in a general endocrine clinic during the last 2 decades. Seventy-four patients (age 4 months to 36 years) were registered during this period. Fifty-two were more than 5 years old at the time of registration. Thirty-five were reared as females, 29 as males; nine children (4 months to 1 year old) were brought for sex assignment, and one (with epispadias) was brought for correction of urinary incontinence. Investigations revealed 28 patients with congenital adrenal hyperplasia, 14 dysgenetic male pseudohermaphroditism, ten true hermaphroditism, six partial androgen insensitivity, four castration and one epispadias. There were eight patients with perineal hypospadias with normal Leydig cell reserve (normal LH, FSH and testosterone response to LHRH). Sex of rearing and gender identity were concordant in all except the patients with perineal hypospadias with normal Leydig cell response. These observations support the theory that prenatal androgen exposure masculinizes the brain.

Imaging in intersex disorders

BACKGROUND Evaluation of the gonads and internal genital structures is an essential component for evaluation of patients presenting with ambiguous genitalia. Ultrasonography (US) and magnetic resonance imaging (MRI) are the two preferred modalities. OBJECTIVE To compare US and MRI in patients with intersex for localization of gonads and internal genitalia. PATIENTS AND METHODS Ten patients with proven intersex disorders were included in the study. Findings from US and MRI were corroborated by those from surgery/laparoscopy. RESULTS For evaluation of the gonads, MRI was found to be marginally more sensitive than US. For internal genital structures, both modalities were found to be equally sensitive and specific with no false positive results. CONCLUSION US still remains the modality of choice for screening patients with intersex disorders. MRI is helpful in cases with equivocal US findings.

Apparent male gender identity in a patient with complete androgen insensitivity syndrome.

Clinicians universally agree on female sex of rearing inpatients with complete androgen insensitivity syndrome(CAIS).Thesepatientshaveafemalephenotypethoughtheyhave an XY karyotype and testis. Long-term studies haveshown an overall patient satisfaction with the assigned fe-male sex, female gender identity, and heterosexual prefer-encesinpatientswithCAIS(Hines,Ahmed,HMazur,2005;Wisniewskietal.,2000).WereporthereacaseofCAIS(rearedasafemaleuntilage11 years)whopresentedwith a desire to live as a male at age 11 years.This 11 year, 3 month old girl was the youngest of fivesiblings (one brother and three sisters). She had undergonesurgery for bilateral inguinal swellings one year prior at alocal hospital. Testicular tissue was found on exploration.The wound was closed without any surgical manipulationand the patient was referred to the endocrine department ofthis hospital. The child was accompanied by father andbrotheratthefirstvisit.ThiswasaHindufamilythathadbeenresiding in a village in Haryana. The father, around 45 yearsof age, was a farmer. The father and brother expressed theirdesire for masculinizing genitoplasty to rear the child as amale.Theyreportedthattheyhadobservedboy-likebehaviorin the child from early childhood and the revelation of thetesticular tissue had made them all convinced about the truemale identity of the child. She had been the most aggressiveamong all the female siblings and her play preferences anddressingpatternweresimilartoherelderbrother.Thepatientreturned with her mother in the subsequent visit (1 monthlater).Motherwasahousewife.Duringthesevisits,thischildwas dressed like a boy, expressed a desire to go to a boy’sschool as a boy, and said that she preferred boy’s company.Oncarefulquestioning,motherrevealedthat,duringthebirthofthischild,bothparentshadnursedastrongdesireforaboyafter three girls were born. She had always preferred a malepattern of dressing for the child and took pleasure in seeingmale appropriate behavior in her. Examination revealed acomplete female phenotype with no development of secon-darysexualcharacters(A1B1P

Insulin response to oral glucose in healthy, lean young women and patients with polycystic ovary syndrome.

Background and aim. Insulin resistance and consequent hyperinsulinemia are common among patients with polycystic ovary syndrome (PCOS). Ethnicity and dietary habits affect insulin levels. There is little published information from India on insulin levels in PCOS patients. Thus the present study aimed to determine the insulin response to oral glucose in women with PCOS and healthy women. Methods. In a case–control study design, women with PCOS and lean healthy women without a family history of diabetes mellitus underwent oral glucose tolerance testing. Samples were collected at 0, 1 and 2 h after glucose ingestion. Results. Two hundred and eighty-five women with PCOS and 27 lean healthy young women were enrolled into the study. The mean age of controls was 22.8 ± 4.5 years (range 15–32 years) and their mean body mass index (BMI) was 19.7 ± 2.6 kg/m2. Mean blood glucose at 0, 1 and 2 h was 88.2 ± 7.2, 115.5 ± 25.5 and 91.8 ± 20.5 mg/dl, respectively. Corresponding plasma insulin levels were 5.8 ± 1.1, 32.7 ± 26.5 and 14.6 ± 9.6 mIU/l. Peak insulin levels were seen at 1 h and these came down to less than 40% of the peak value by 2 h. Glucose/insulin ratio at 0, 1 and 2 h was 15.6 ± 3.1, 7.0 ± 3.1 and 11.4 ± 7.0. Homeostasis model assessment of insulin resistance (HOMA-IR) was 1.2 ± 0.2. The age of the PCOS women ranged from 15 to 40 years (mean 23.4 ± 6.2 years) and their BMI ranged from 16.4 to 50.4 kg/m2 (mean 27.7 ± 6.3 kg/m2). One hundred and seventy-six (62%) PCOS patients had normal glucose tolerance (NGT), 39 (14%) had impaired fasting glucose (IFG), 49 (17%) had impaired glucose tolerance (IGT) and 21 (7%) had type 2 diabetes mellitus (T2DM). Insulin response was higher in women with PCOS. Peak insulin was observed at 1 h. The difference between 1-h and 2-h post-glucose insulin decreased with worsening glucose tolerance. Both plasma insulin and BMI showed a rising trend from NGT to IFG to IGT. There was no further increase in either insulin or BMI from IGT to T2DM. Glucose/insulin ratio at 0, 1 and 2 h was lower (8.3 ± 4.2, 2.0 ± 1.6 and 3.2 ± 3.5) than that of healthy controls. HOMA-IR was 3.1 ± 3.0. Conclusion. Women with PCOS had an exaggerated insulin response to glucose. Thirty-eight percent of PCOS women had some form of abnormal glucose tolerance. Greater insulin response was seen with impairment of glucose tolerance. Obesity had no effect on fasting insulin or insulin response to oral glucose in PCOS women with NGT.