D. Engelhardt

SERUM ANDROGENS IN INTENSIVE-CARE PATIENTS : CORRELATIONS WITH CLINICAL FINDINGS

Serum androgen levels were studied In 100 patients (50 male) with varying degrees ot severe illness, determined by Acute Physiological and Chronic Health Evaluation (APACHE). Comparison with normal subjects revealed the following changes:

Different inhibitory effect of etomidate and ketoconazole on the human adrenal steroid biosynthesis

SummaryThe narcotic agent etomidate and the antimycotic drug ketoconazole are known to block steroid biosynthesis in man. To study the different effects of these imidazole derivatives on human adrenal steroid biosynthesis we incubated slices of human adrenal glands with 3H-labeled precursors and increasing concentrations of etomidate or ketoconazole (0-2000 μM). After extraction the labeled metabolites were separated by thin-layer chromatography and quantified by scintillation counting. Etomidate inhibited most potently 11β-hydroxylase activity by suppressing the formation of corticosterone from 11-deoxycorticosterone to 1 % of control [50% inhibitory concentration (IC50) 0.03 μM] while ketoconazole suppressed 11β-hy-droxylase to only 39% of control activity (IC50 15 μM). Ketoconazole however, most potently blocked the conversion of 17α-hydroxy-proges-terone to androstenedione by C17,20-desmolase to about 15% of control activity (IC50 1 μM) while etomidate showed a much weaker effect on this enzyme with a suppression to 50% of C17,20-desmolase control activity at a concentration of 380 μM. Both imidazole drugs showed a similar strong inhibitory effect on the activity of 17α-hy-droxylase (IC50 6-18 μM) and 16α-hydroxylase (IC50 4–8 μM) and did not affect 21-hydroxylase. These in vitro data indicate a predominant inhibitory effect of etomidate on corticosteroid biosynthesis by relative selective inhibition of 11β-hydroxylase and of ketoconazole on the adrenal androgen biosynthesis by a predominant inhibition of C17,20-desmolase. This differential inhibitory effect of etomidate and ketoconazole on human steroid biosynthesis may be of clinical importance for a possible therapeutic use of these imidazole derivatives in endocrine disorders.

Ketoconazole inhibits cortisol secretion of an adrenal adenoma in vivo and in vitro

SummaryKetoconazole (Nizoral), an oral broad spectrum antifungal agent, inhibits ergosterol synthesis in fungi and cholesterol synthesis in mammalian cells by inhibition of the 14-demethylation of lanosterol. After a blunted cortisol response to ACTH in normal men after ketoconazole has been shown by others we studied the influence of the antifungal agent on the cortisol secretion in a patient with a cortisol producing adrenal adenoma in vivo and in vitro. Repeated oral doses of ketoconazole (200 mg every 5 h over a period of 48 h) induced a reproducible clear cutt fall of serum cortisol levels under 2.5 µg/dl. The inhibitory effect on the cortisol secretion could be detected first 5 h after the first dose, 9 h after the last dose cortisol levels recovered. In addition the inhibitory effect of ketoconazole on cortisol secretion could be reproduced in vitro by incubating tissue slices of the excised adrenal tumor together with the antifungal agent in concentrations equivalent to therapeutic serum levels. These findings emphasize that patients with an autonomous cortisol production caused by an adrenal tumor are proned to dangerous hypoadrenalism if treated with ketoconazole.

17β-Hydroxysteroid-Oxydoreduktase-Mangel bei Pseudohermaphroditismus maskulinus vom Typ des Reifenstein-Syndroms

SummaryA boy with male pseuodhermaphroditism described here with normal male caryotype was at first raised as a girl. The error was detected within the first year of life.At the age of 12 years the boy developed a severe gynecomastia. At this time determinations of plasma and urinary steroids were undertaken.17-ketosteroids and total 17-OHCS were determined by colorimetry. Plasma testosterone, androstenedione, 17α OH-progesterone, urinary pregnantriol and pregnantriolone were measured by GLC. Plasma estrone and estradiol were determined by radioimmunoassay (RIA).Investigations at 12 years of age and later revealed plasma testosterone in the lower normal range and androstenedione 9–23 times higher compared to normal boys.Plasma estrogens were found to be elevated, estrone much more than estradiol.Incubation studies with testicular tissue showed very little conversion of3H-androstenedione (15%) whereas normal testicular tissue converted up to 60% to3H-testosterone.On the basis of these data 17β-hydroxysteroid-oxydoreductase deficiency is suggested as the underlying cause of pseudohermaphroditism and gynecomastia in this boy.Up to the present this enzyme deficiency is described only two times but it would seem to be more frequent if one looked at the elevated androstenedione plasma level.ZusammenfassungBeschreibung eines Jungen mit Pseudohermaphroditismus maskulinus, mit normalem männlichen Karyotyp, welcher bei der Geburt als Mädchen angesehen worden war. Mit 12 Jahren Auftreten einer hochgradigen Gynäkomastie. Steroiduntersuchungen wurden mit Radiogaschromatographie und mit radioimmunologischen Methoden durchgeführt.Die Steroidbestimmungen ergaben im Plasma bei altersnormalen Testosteronspiegeln Androstendionwerte, welche die Norm um den Faktor 9–23 überstiegen. Die Plasmaoestrogene wurden insgesamt erhöht gefunden, Oestron weit mehr als Oestradiol.In Inkubationsversuchen vom bioptisch gewonnenen Hodengewebe des Jungen konnte gezeigt werden, daß zugesetztes markiertes Androstendion nur in geringem Maß zu Testosteron metabolisiert wurde, während normales Hodengewebe rund 60% zu Testosteron metabolisierte.Auf Grund dieser biochemischen Befunde wird eine Testosteron-Synthesestörung mit Defekt einer 17β-Hydroxy-steroid-Oxydoreduktase als Ursache des Pseudohermaphroditismus und der Gynäkomastie angenommen. Der Enzymdefekt ist bisher zweimal beschrieben, scheint aber nach entsprechender Untersuchung häufiger zu sein.

Different therapeutic efficacy of ketoconazole in patients with Cushing's syndrome

SummaryThe property of ketoconazole to inhibit adrenal biosynthesis of cortisol was used in a clinical study of 14 patients with Cushings syndrome (pituitary-dependent Cushings disease,n=10; adrenocortical adenoma,n=2; adrenocortical carcinoma,n=1; ectopic ACTH syndrome,n=1). Five patients were treated in a short-term manner (1000 mg over 24 h) and nine patients for a longer period (600 mg/die from 1 week up to 12 months). After short-term administration of ketoconazole, serum cortisol levels fell distinctly only in the patient with adrenocortical adenoma, but not at all or only slightly in the other patients, whereas serum levels of progesterone and 11-deoxy-compounds increased markedly in all patients, with the exception of the patient with adrenocortical carcinoma. Plasma ACTH levels increased in the patients with Cushings disease but not in the patients with tumor. After long-term treatment of three patients with Cushings disease over 3, 10, and 12 months, the clinical signs of hypercortisolism persisted or were only slightly ameliorated. In these three patients as well as in three other patients with Cushings disease treated for a shorter period of 1 to 4 weeks, serum and urinary cortisol levels decreased, but were not normalized, whereas plasma ACTH levels increased variably. Only in one patient with Cushings disease, in the second patient with adrenocortical adenoma, and in the patient with ectopic ACTH syndrome, serum and urinary cortisol levels returned to normal. We concluded from our data, that the antimycotic drug inhibits biosynthesis of cortisol by blocking adrenal 11β- and 17α-hydroxylase activity. This effect was compensated in part by a rebound increase of pituitary ACTH secretion in most patients with Cushings disease. Therefore, ketoconazole treatment is above all effective in patients with Cushings syndrome due to an adrenal tumor or in patients with ectopic ACTH syndrome, who cannot respond with an increased pituitary ACTH secretion.

Inhibition of human adrenal androgen secretion by ketoconazole

SummaryThe effect of ketoconazole on adrenal androgen secretion was examined in 15 patients with elevated serum androgens. In a dose of 600 mg per day orally ketoconazole inhibited the biosynthesis of all measured androgens. The mean reduction in serum levels of dehydroepiandrosterone sulfate was 32%, of dehydroepiandrosterone 54%, of androstenedione 52%, and of testosterone 43%; mean serum levels of cortisol only fell by 19%. The reduction in serum androgen levels was first significant 24 h after beginning of treatment and persisted as long as the drug was administered. We conclude that ketoconazole inhibits adrenal androgen biosynthesis more pronouncedly than cortisol biosynthesis. This might be of clinical benefit in the treatment of hirsutism and other states of androgen hypersecretion.

Untersuchungen über den Stoffwechsel von Testosteron und Δ4-Androstendion in der Leber des Menschen

SummaryHuman liver tissue obtained by needle biopsy was incubated with (4-14C)-testosterone and (1,2-3H)-androst-4-enedione and the interconversion and catabolism of these androgenic hormones were investigated by a radio-gas chromatographic method. The rate of metabolism of testosterone in histologically normal hepatic tissue was as high as in cirrhotic tissue, while the rate of metabolism in fatty liver was lower. The catabolism of androst-4-enedione in normal liver tissue of women was three times higher than in that of men; metabolism of androst-4-enedione in cirrhotic tissue was also higher than in normal tissue. The interconversion of testosterone to androst-4-enedione by normal tissue of men was much higher than in women. Testosterone and androst-4-enedione catabolism to 5β-metabolites was greater than that to 5α-metabolites.ZusammenfassungLeberstanzcylinder, gewonnen durch Blindpunktion, wurden mit (4-14C)-Testosteron und (1,2-3H)-Δ4-Androstendion inkubiert und die Interkonversion sowie der Katabolismus dieser Androgene in vitro mit Hilfe einer radiogaschromatographischen Methode untersucht. Es zeigte sich, daß Testosteron durch histologisch normales und cirrhotisches Lebergewebe in der gleichen Größenordnung abgebaut wurde, durch Fettlebergewebe dagegen in geringerem Ausmaß. Der Abbau von Δ4-Androstendion durch normales Lebergewebe von Frauen war etwa 3mal größer als von Männern; auch die cirrhotische Leber von Männern baute mehr Δ4-Androstendion ab als die normale. Die Interkonversion von Testosteron in Δ4-Androstendion war durch normales Lebergewebe von Männern wesentlich höher als von Frauen. Abgebaut wurde Testosteron und Δ4-Androstendion mehr zu 5β-hydrierten Metaboliten als zu 5α-hydrierten Verbindungen.

17-Ketosteroid Reductase Deficiency - Plasma Steroids and Incubation Studies with Testicular Tissue

In infancy, the proposita was diagnosed as a case of testicular feminisation. At the age of 14 she suffered from severe symptoms of virilising puberty with poor breast development. Plasma steroid analyses revealed a tenfold elevated androstenedione concentration (Δ4 = 1562 ng/dl).Testosterone (T = 266 ng/dl) was in the pubertal range.Thus the Δ4/T-ratio was far above normal. The estrone/estradiol ratio was also elevated (E1/E2 = 10.2/2.2 ng/dl ). Δ4,T,E1,and E2 could not be suppressed by dexamethasone, but reacted promptly to fluoxymesterone (Δ4 =781 ng/dl).HCG caused a further increase of the Δ4/T-ratio(2220/246 ng/dl); ACTH did not alter the Δ4-concentration. These findings together with similar investigations after gonadectomy suggest that the failure to convert Δ4 to T and E1 to E2 is restricted to the testes. In-vitro incubations of testicular tissue showed almost no 17-ketosteroid reductase activity.This form of male pseudohermaphroditism can easily be detected already in infancy, if steroid analyses and stimulation tests are performed, and patients should be submitted to early orchidectomy in order to avoid virilisation in puberty.