Gianni Russo

Clinical presentation of McCune-Albright syndrome in males.

UNLABELLED The aims of this study were: (a) to survey gender prevalence and clinical findings at diagnosis in a series of patients who manifested at the time of this study the classical triad of McCune-Albright syndrome (MAS); (b) to investigate whether clinical presentation of MAS in boys may be different from that in girls; (c) to confirm whether boys with MAS may show a peculiar picture of testicular microlithiasis (TM) by testicular ultrasonography (US). Twenty-six patients (10 boys) with the classical clinical manifestations of MAS were recruited for the present study from the database of the Italian Multicenter Study Group on MAS. Age at diagnosis of MAS was significantly lower in girls than in boys (p < 0.025). Whilst there was no difference in the prevalence of skin and bone fibrous dysplasia for the two groups, a significantly higher prevalence of peripheral precocious puberty (PPP) was found in girls (chi2 = 6.5, p < 0.025). Moreover, PPP onset was earlier in females than in males (2.8 +/- 2.3 vs. 6.9 +/- 2.7 years, p < 0.005). In one boy, aged 2.9 years, the first clinical manifestation of MAS was monolateral testicular enlargement in the context of a picture of classical PPP. US scanning of the testes, at the time of the present study, showed bilateral hyperechogeneic multiple spots, compatible with diagnosis of TM, in 6/10 boys. CONCLUSIONS (a) MAS is slightly more frequent in females. (b) PPP in MAS is significantly more frequent and earlier in girls. (c) PPP in boys with MAS is generally associated with bilateral testicular enlargement, but monolateral macroorchidism may also be seen. (d) TM may be another marker for MAS in males.

17β-Hydroxysteroid dehydrogenase-3 deficiency: From pregnancy to adolescence

Objective: Aim of this study is to report on basal clinical phenotype and follow up after diagnosis, of patients with 17β-hydroxysteroid-dehydrogenase type 3 (17β-HSD3) deficiency in Italy. Setting: Pediatric Endocrine Departments, University Hospitals. Patients: The cases of 5 Italian subjects affected by 17β-HSD3 deficiency are presented in this study. Interventions: Laboratory and genetic assessment. Gonadectomy and female sex assignment (4 patients) or GnRH analog therapy to regress puberty and gender identity disorder (1 patient). Results: Presentation lasted from pregnancy (pre-natal diagnosis of a 46,XY fetus with female external genitalia) to infancy (inguinal hernia containing testes/clitoromegaly) and adolescence (virilisation). All subjects but one (subject 1, Central-Northern Italy) were from small areas of Southern Italy. Endocrine data (baseline and/or stimulated testosterone/A4-androstenedione ratio) were informative. Two girls were homozygous for 17β-HSD3 gene mutations (G289S/G289S; R80W/R80W), while the others were compound heterozygous (IVS325+4 A>T/A203V; L212Q/M235V; R80W/A235E). Four patients were confirmed as females and were well-adjusted with assigned sex; gender identity disorder improved during treatment with GnRH analog in the last subject. Conclusions: 17βHSD3 deficiency may present from pregnancy to puberty for different clinical issues. Albeit testosterone/A4-androstenedione ratio represents the most accurate endocrine marker to diagnose the disorder, hCG-stimulation is mandatory in pre-puberty. Molecular analysis of 17β-HSD3 gene should be performed to confirm the diagnosis. Temporary GnRH analog treatment may regress gender identity disorder and provide time to confirm or change the birth sex assignment. Female individuals seems to be compliant with their sex, providing that virilisation does not occur. In Italy, the disorder seems to be more prevalent in the Southern regions and shows genetic heterogeneity.

Testis development in the absence of SRY: chromosomal rearrangements at SOX9 and SOX3

Duplications in the ~2 Mb desert region upstream of SOX9 at 17q24.3 may result in familial 46,XX disorders of sex development (DSD) without any effects on the XY background. A balanced translocation with its breakpoint falling within the same region has also been described in one XX DSD subject. We analyzed, by conventional and molecular cytogenetics, 19 novel SRY-negative unrelated 46,XX subjects both familial and sporadic, with isolated DSD. One of them had a de novo reciprocal t(11;17) translocation. Two cases carried partially overlapping 17q24.3 duplications ~500 kb upstream of SOX9, both inherited from their normal fathers. Breakpoints cloning showed that both duplications were in tandem, whereas the 17q in the reciprocal translocation was broken at ~800 kb upstream of SOX9, which is not only close to a previously described 46,XX DSD translocation, but also to translocations without any effects on the gonadal development. A further XX male, ascertained because of intellectual disability, carried a de novo cryptic duplication at Xq27.1, involving SOX3. CNVs involving SOX3 or its flanking regions have been reported in four XX DSD subjects. Collectively in our cohort of 19 novel cases of SRY-negative 46,XX DSD, the duplications upstream of SOX9 account for ~10.5% of the cases, and are responsible for the disease phenotype, even when inherited from a normal father. Translocations interrupting this region may also affect the gonadal development, possibly depending on the chromatin context of the recipient chromosome. SOX3 duplications may substitute SRY in some XX subjects.

Body composition and metabolic profile in women with complete androgen insensitivity syndrome.

Clinical and experimental data suggest that androgen receptor (AR) signaling plays a role on body composition, glucose homeostasis and lipid metabolism. The effect of AR disruption on such parameters was not extensively investigated in human people. A group of young to middle-age adult women with complete androgen insensitivity syndrome (CAIS, n = 18, age 32.2 ± 9.3 years; women with testes removed n = 14) was investigated for body mass index (BMI), body composition (dual energy X-ray absorptiometry), serum glucose levels, insulin sensitivity (HOMA-IR) and lipid profile. Mean BMI (24.2 ± 7.4 kg/m2) was not significantly increased (T-score 1.0 ± 2.5, p = NS vs Italian female reference values), but prevalence of obesity was higher in women with CAIS than that reported in age-related Italian females (16.7% vs 3.6%, respectively). The majority of obese individuals with CAIS was in the subgroup with intact testes (3/4). DXA assessment (n = 15) demonstrated values of total free fat mass similar to that of 46,XX female controls. Increased body fat was found in CAIS women in comparison with both female and male controls. Abnormal values of cholesterol (total and LDL) and HOMA-IR were present in a large subset of patients. Our data suggest that in women with CAIS disruption of AR signaling may increase body fat and affect some metabolic parameters. Assessment of body composition, metabolic profile and, likely, cardiovascular risk seems to be advisable with ageing in these individuals.

Central Precocious Puberty: Treatment with Triptorelin 11.25 mg

Background. Few data are available on quarterly 11.25 mg GnRH analog treatment in central precocious puberty (CPP). Aim. To assess the efficacy of triptorelin 11.25 mg in children with CPP. Patients. 17 patients (16 females) with CPP (7.9 ± 0.9 years) were treated with triptorelin 11.25 mg/90 days. Methods. Gonadotropins, basal-, and GnRH-stimulated peak, gonadal steroids, and pubertal signs were assessed at preinclusion and at inclusion visit, 3 months, 6 months, and 12 months of treatment. Results. At 3, 6, and 12 months, all patients had suppressed LH peak (<3 IU/L after GnRH stimulation), as well as prepubertal oestradiol levels. Mean LH peak values after GnRH test significantly decreased from 25.7 ± 16.5 IU/L at baseline to 0.9 ± 0.5 IU/L at M3 (P < 0.0001); they did not significantly changed at M6 and M12. Conclusions. Triptorelin 11.25 mg/90 days efficiently suppressed the pituitary-gonadal axis in children with CPP from first administration.

Early onset of puberty in young girls: An Italian cross-sectional study

Background: International literature and clinical practice have referred to Marshall and Tanner data to define the physiological age at onset of puberty. A study in the United States (1997) showed an anticipation in pubertal onset, whereas several European studies did not confirm this trend. Aim: To describe the onset of secondary sexual characteristics in a large Italian population of girls and to compare it to reference literature data. Subjects and methods: A cross-sectional study on 7311 2–14-yr-old girls who spontaneously requested a clinical evaluation for routine health check-up or acute illness by family pediatrician’s offices in a northern Italian region (Lombardy), between September 2005 and November 2006. Trained family pediatricians performed a complete physical examination; pubertal status was evaluated following Tanner’s criteria; breast development was assessed by palpation. Results: Mean age of thelarche (B2), pubarche (PH2), menarche were 9.75, 10.09, and 12.49 yr, respectively. The prevalence of B2 and PH2 at ages 7–7.99 was 5.9% and 5.6%, respectively, at ages 8–8.99 was 15.5% and 13.8%, respectively. Mean time lapse from B2 to B3 and B2 to menarche was 1.46 and 2.74 yr, respectively. Mean age at menarche of our population and their respective mothers was almost identical. Conclusions: Our population presented earlier clinical signs of pubertal development than those defined by Marshall and Tanner. Mean age of menarche was not different in comparison to the previous generation. A different progression of pubertal development was found, in which the shift to B3 may have more clinical relevance.

5α-Reductase-2 Deficiency: Clinical Findings, Endocrine Pitfalls, and Genetic Features in a Large Italian Cohort.

Clinical records (n = 24) with an established diagnosis of 5α-reductase-2 deficiency were reviewed. A previous misdiagnosis was present in about 70% (period from first observation to definitive diagnosis: 9.1 ± 10.8 years), and in 8 children gonadal removal was performed before certain diagnosis. Initial sex assignment was female in 16/24 (67%) and male in 8/24 (33%) cases. After diagnosis, sex re-assignment was performed in 5 babies (4 girls to male sex; 1 boy to female sex). Baseline testosterone/DHT ratio was diagnostic in 6/12 subjects (first months of life n = 4; puberty n = 2), while post-hCG testosterone/DHT ratio was diagnostic in all tested individuals (choosing both the cut-off value 15 or 10). Eighteen different mutations in the steroid-5α-reductase-2 (SRD5A2) gene were identified, 5 of which have never been reported. In conclusion, a time lag exists before the diagnosis of 5α-reductase-2 deficiency is established; sex assignment and gonadal removal may be performed before certain diagnosis. Sex re-assignment is usually female to male, but the contrary may occur. A large variability in clinical phenotypes and genetic mutations was present in this cohort. Accurate endocrine evaluation is recommended in babies possibly affected by 5α-reductase-2 deficiency, since the use of appropriate cut-off values of testosterone/DHT ratio after hCG stimulation may permit to select individuals for SRD5A2 gene analysis. A genotype-phenotype correlation was not found in this study.

Germline prokineticin receptor 2 (PROKR2) variants associated with central hypogonadism cause differental modulation of distinct intracellular pathways.

INTRODUCTION Defects of prokineticin pathway affect the neuroendocrine control of reproduction, but their role in the pathogenesis of central hypogonadism remains undefined, and the functional impact of the missense PROKR2 variants has been incompletely characterized. MATERIAL AND METHODS In a series of 246 idiopathic central hypogonadism patients, we found three novel (p.V158I, p.V334M, and p.N15TfsX30) and six already known (p.L173R, p.T260M, p.R268C, p.V274D, p.V331M, and p.H20MfsX23) germline variants in the PROKR2 gene. We evaluated the effects of seven missense alterations on two different prokineticin receptor 2 (PROKR2)-dependent pathways: inositol phosphate-Ca(2+) (Gq coupling) and cAMP (Gs coupling). RESULTS PROKR2 variants were found in 16 patients (6.5%). Expression levels of variants p.V158I and p.V331M were moderately reduced, whereas they were markedly impaired in the remaining cases, except p.V334M, which was significantly overexpressed. The variants p.T260M, p.R268C, and p.V331M showed no remarkable changes in cAMP response (EC50) whereas the IP signaling appeared more profoundly affected. In contrast, cAMP accumulation cannot be stimulated through the p.L173R and p.V274D, but IP EC50 was similar to wt inp.L173R and increased by 10-fold in p.V274D. The variant p.V334M led to a 3-fold increase of EC50 for both cAMP and IP. CONCLUSION Our study shows that single PROKR2 missense allelic variants can either affect both signaling pathways differently or selectively. Thus, the integrity of both PROKR2-dependent cAMP and IP signals should be evaluated for a complete functional testing of novel identified allelic variants.

46,XY Karyotype in a Female Phenotype Fetus: A Challenging Diagnosis

BACKGROUND The growing use of prenatal investigations allows an early detection of several inborn disorders, including disorders of sexual development. The management of these conditions is an arising problem. CASE 46,XY karyotype and female phenotype were detected in a fetus; 5α-reductase and androgen receptor gene analysis on chorionic villi revealed no relevant mutation. The newborn was assigned to female sex. The diagnosis of 17β-hydroxysteroid dehydrogenase-3 β-OL deficiency was reached at four months of age, by means of a low testosterone/Δ 4-androstenedione ratio after HCG test and HSD17B3 gene analysis. SUMMARY AND CONCLUSION A 46,XY fetus with female external genitalia suggests different conditions, some very rare. Specific genetic investigations should be performed prenatally when possible. A complete evaluation is mandatory after delivery to reach a correct diagnosis.

Kallmann's syndrome and normosmic isolated hypogonadotropic hypogonadism: two largely overlapping manifestations of one rare disorder

Central hypogonadism (CHg) is a disorder caused by an insufficient GnRH stimulation of an otherwise intact pituitary–gonadal axis. It is also called isolated or congenital gonadotropin-releasing hormone (GnRH) deficiency or isolated hypogonadotropic hypogonadism (IHH). CHg may be either congenital or acquired, and can either be secondary to hypothalamic or pituitary dysfunctions. Isolated CHg is a rare disease with an incidence of 1:8,000 males and 1:40,000 females. It can either be associated with a normal or defective sense of smell, respectively, identifying the normosmic CHg (nCHg or nIHH) or the Kallmann’s syndrome (KS). Males frequently present with defective androgenization and growth at peripubertal age but micropenis and cryptorchidism may already be evident in the neonatal period, indicating a defective HPG activation during the prenatal development. Females generally present with primary amenorrhea and growth retardation. Additional neurological (e.g., anosmia, bimanual synkinesia) and non-neurological defects (e.g., the midline or kidney defects) may frequently co-exist and be linked to specific modes of inheritance. Indeed, KS was originally described as caused by mutations in a specific X-chromosome gene, KAL-1 (reviewed in ref. [1]), with a consequent altered targeting of olfactory axons and migration of neurons producing GnRH, the key central regulator of the reproductive axis, but this genetic defect was soon found to be present in a minority of the patients. Thus the causal event of the isolated CHg was often missing and the classification of ‘‘idiopathic’’ IHH or CHg was consequently adopted. Nevertheless, the observation of familial cases with variable modes of inheritance (X-linked or autosomal dominant or recessive) soon indicated that IHH or CHg retains a highly heterogeneous genetic component. The application of conventional linkage studies to investigate the genetic basis has proven difficult, because most pedigrees tend to be of small size, since the majority of patients remain infertile in the absence of therapeutic treatment. In the last decade, however, the knowledge on the pathogenesis of CHg has been profoundly deepened thanks to the utilization of animal and cellular models; these, together with the application of modern techniques of genetic investigation, brought evidence of previously unknown genetic determinants of IHH (either nCHg or KS). These new insights have played a significant role in disclosing the physiological complexities of the HPG axis and therefore in elucidating the pathophysiology of IHH. Association with a multitude of candidate genes has nowadays been identified [1]. Some genes are determinant for the correct embryonic differentiation of the GnRH-secreting neurons, such as the receptor-ligand pair fibroblast growth factor receptor 1; fibroblast growth factor 8 (FGFR1/FGF8), nasal embrionic LH releasing hormone factor (NELF) and heparan sulfate 6-O-sulfotransferase 1 (HS6HST1). Other genes encode the signals essential for the correct migration of the GnRH neurons form their embryonic origin to the hypothalamus, such as the KAL-1, the ligand–receptor complex prokineticin 2 and its receptor (PROK2/PROKR2), the chromodomain helicase DNA binding protein 7 (CHD7) and SEMA3A (members of the class 3 Semaphorins). Other genes encode the elements of upstream signals contributing to the activation of GnRH neuron, such as the two ligand–receptor couples formed either by the TAC3/TACR3 (tachykinin 3 and its receptor also named neurokinin B, NKB, and/or neurokinin 3 The members of the NICe group are listed in ‘‘Appendix’’.