M G Forest

3β-Hydroxysteroid Dehydrogenase Deficiency Follow-Up Study in a Girl with Pubertal Bone Age

Follow-up data on a girl with 3 beta-hydroxysteroid dehydrogenase deficiency at a pubertal bone age are presented. On examination at age 14.7 years (bone age 12 years), there was no spontaneous breast development. On treatment with hydrocortisone and fludrocortisone, most steroids with the exception of increased 17OH-pregnenolone in plasma and delta 5-pregnenetriol and pregnanetriol in urine, were normal. After 1 week off hydrocortisone, plasma 17OH-pregnenolone, DHA and delta5-androstenediol and urinary delta 5-pregnenetriol and pregnanetriol increased markedly, while plasma 17OH-progesterone increased only slightly. On increased hydrocortisone medication, there was no response of plasma estradiol to HMG. This first observation of a pubertal girl with 3 beta-hydroxysteroid dehydrogenase deficiency indicates that in this patient, the defect persists at a pubertal bone age and that it is not limited to the adrenals, but also affects the ovaries. Girls with this type of defect thus require estrogen replacement at a bone age of about 12 years. The large quantities of pregnanetriol in the urine are not due to an incomplete defect or an additional 21-hydroxylase deficiency, but most likely to the peripheral or hepatic conversion of 17OH-pregnenolone or delta 5-pregnenetriol.

Partial 17, 20-desmolase and 17α-hydroxylase deficiencies in a 16-year-old boy

Thirteen plasma steroids as well as ACTH, LH and FSH were measured by specific RIAs under basal and dynamic conditions in a 16-year-old boy (normal external genitalia, 46, XY karyotype) who presented slowness and unachievement of pubertal development. On the Δ4-pathway: basal levels of testosterone and dihydrotestosterone were low — with a normal ratio-, Δ4-androstenedione and 11β-hydroxyandrostenedione were in the low normal range. Meanwhile, 17α-hydroxyprogesterone and progesterone levels were markedly elevated. On the Δ5-pathway: dehydroepiandrosterone was extremely low while 17α-hydroxypregnenolone and pregnenolone were almost normal; dehydroepiandrosterone sulfate was subnormal while pregnenolone sulfate was normal. Cortisol, aldsoterone were normal while ACTH was moderately increased. Basal and responsive levels of LH and FSH were markedly increased. ACTH stimulation induced asubnormal rise of Cortisol and 11 β-hydroxyandrostenedione, a low or absent rise of dehydroepiandrosterone, 17α-hydroxypregnenolone, androstenedione and 17α-hydroxyprogesterone contrasting with a marked rise of pregnenolone and progesterone. After hCG stimulation, responses were low for testosterone, extremely high for 17α-hydroxyprogesterone with a normalisation of the 17α-hydroxyprogesterone/progesterone ratio. Fluoxymesterone dramatically reduced the pathologically high basal levels of progesterone and 17α-hydroxyprogesterone. Dexamethasone induced only a minute decrease in the A4-progestagens, a marked decrease in pregnenolone, with a more than 80% reduction of 17α-hydroxypregnenolone, dehydroepiandrosterone, dehydroepiandrosterone sulfate and androstenedione. These data suggest a defect involving the cytochrome P450 common to both 17α-hydroxylase and 17,20-desmolase activities. In the testis, the alteration is already present in basal state and mainly expressed in its 17,20-desmolase activity whereas in the adrenal, it is only expressed in its 17a-hydroxylase component. The different behavior of adrenals and testes regarding this common defect is probably due to local factors affecting specifically the tissue expression of the enzyme.

17–20 Desmolase deficiency in two unrelated prepubertal and adolescent boys previously diagnosed as simple hypospadias

In the 2 patients,8½ and 13yrs old,attention was drawn in the course of plastic surgery for perineoscrotal hypospadias by the small size of the phallus,the testis were palpable in the scrotum and there was a normal androgen sensitivity.In the older boy a small vaginal pouch was found;pubertal changes in hypothalamopituitary secretion were shown in the LHRH test (FSH:2,8-7;LH:5,6-60mIU/ml) and a large gynecomastia subsequently developped.Diagnosis of the enzyme defect was made by systematic endocrine studies in plasma (ng/dl) basal levels of testosterone (T),Androstenedione (A),DHA and DHAS were very low,while those of 17-OH progesterone (OHP)were very high (362 and 358).Dynamic studies were strikingly similar in both cases:no rise in plasma A and DHA after 250 μg/m2 of ACTH IV, an abnormally low rise in T (82 and 112) after HCG(7×1500 IU every other day) contrasting with an enormous rise in OHP after both ACTH (2330) and HCG (2757 and 964).Cortisol and aldosterone responses to ACTH were normal.In the urines (mg/day) the post ACTH rise in 17-OHSter olds were abnormally high (30.6 and 53.9)as compared with that of the ketogenic steroids (49.4 and 35.2).In the younger boy abnormally high levels of pregnanetriolone were found before(1.8) as well after ACTH (14.9).In conclusion,any child even with small ambiguity of his genitalia should benefit of detailed endocrine studies which may reveal that 17-20 Desmolase deficiency is not an exceptional disease.

123 LATE ONSET 21-OH-DEFICIENCY (21-OHD) CAN BE MISDIAGNOSED AS |[ldquo]|TYPICAL PREMATURE PUBARCHE|[rdquo]| (PP) IN CHILDHOOD

The isolated and early growth of pubic hair (PH) is often associated with slight advance in bone age (BA) and statural age (SA). Diagnosis of PP is classically made on high levels of dehydroepiandrosterone sulfate (DS). In this context, measuring only DS can be misleading, as we observed in 5 girls. The first 3 were seen at 5.5 yr for PP with normal SA ; their basal levels of DS (μg/dl) were indeed very high for age (135, 40 and 73 respectively). The last 2 girls were seen at 6-8 yr for early onset of PH (5-7 yr) and tall stature ; DS levels (63-94 and 86-158) were also very high. BA was advanced but not so drastically when reported to SA, except in girl n° 3. 21-OHD, suspected only in girl n° 5, was recognized in all girls on the systematic or retrospective (n° 1) measurement of 17-OH-progesterone (OHP) levels (ng/dl) which were variably elevated between girls (287 to 5372), but even more variable between days in each of them (ex: 87 to 2731 in n° 4). In girls n° 1, 3 and 4, OHP as well as DS were normally suppressed with Dexamethasone. Girl n° 1, misdiagnosed as PP until 16 yr, had normal menses from 12.7 yr onwards, still had high DS (362) and OHP (1246) levels at 18 yr but refused Rx. In girls n° 4 and 5, now treated for 2-3 yr, DS returned slowly to normal for age. In both girls, HLA-typing revealed the B14 antigen.In conclusion: 1) DS levels are high from a very young age in children with late onset or partial 21-OHD, in contrast to what observed in CAH newborns (Ped. Res., 1982, 16, 10); 2) Because 21-OHD can mimic the clinical and biological symptoms of “classical” PP, OHP should be measured systematically in children with PP.

Determination of 14 steroid hormones in amniotic fluid (AF): its usefulness in the antenatal diagnosis of 21-hydroxylase deficiency

In 63 AF of normal pregnancies (14-20 wks), AF levels of testoster one (T), androstenedione (Δ4) were higher in males, while those of pregnenolone (Preg), 17OH-pregnenolone (17OH-preg), 17OH-progesterone (OHP), DHA, Δ5-androstenediol and 17β -estradiol were slightly but significantly higher in females. There was no sex difference in AF levels of preg. sulfate (PS) or DHA sulfate, progesterone, estrone, cortisol and cortisone. Among 4 pregnancies at risk for congenital adrenal hyperplasia (CAH) due to 21-hydroxylase defect, antenatal diagnosis (Dgs) of CAH was made in 1, on the high AF levels of OHP and confirmed at birth. We then investigated whether estimating AF levels of other steroids could consolidate the Dgs. In the AF of the affected girl, T, Δ4 were also drastically elevated, PS, preg and 170Hpreg were just above normal limits (NL), while the other hormones were normal. Similarly T, Δ4 and OHP were drastically elevated in the peripheral blood at birth. In contrast none of the estimations in the cord blood would have made the dgs with certainty, although OHP was above normal. In conclusion the simultaneous measurement of T, Δ4 and OHP may prove to be safer for the definitive antenatal dgs of CAH than single hormone analysis.

SEX HORMONE BINDING PROTEIN (SBP) AS A MARKEh OF ANDROGEN SENSITIVITY IN INFANTS AND CHILDREN

Establishing a reliable test of androgen sensitivity is still prerequisite for etiological diagnosis in infants suspected of androgen insensitivity syndrome (AIS). Since androgens are known to decrease SBP levels we have investigated the possibility of using plasma SBP as a marker of androgen sensitivity, and studied the conditions for a rational protocol. The ontogenic pattern of SBP from birth to adulthood was first established in 695 controls, (by a solid phase method). SBP levels (μg/l) low at birth, (6.3±3) rise to 22.3±7.5 during the first month of life correlatively with time, with no sex difference but large individual variations. In addition, SBP decreased significantly after either an acute or a 3-day routine ACTH test. Whatever the age (1 mo-13 yr ), SBP levels decreased significantly (mean=30%) in a group of 40 boys at the end (day 14) of an hCG test (1500 IU/48 h × 7), but the response was very variable and not correlated with testosterone levels. In contrast, the exogenous administration of fluoxymesterone (10 mg/m2/d.x 10 d.) or depo-testosterone (4 IM injections of 100 mg/m2 every 2 weeks) induced a siginificant drop (mean 2 fold) in 10 infants with idiopathic male pseudohermaphroditism, but not in 2 suspected of AIS.In conclusion. SBP appears a good marker of androgen sensitivity in infancy, however establishing a protocol requires three conditions: 1) the test should not be done during the 1st month of life (rising basal levels), 2) neither after an ACTH test and 3) utilise the exogenous administration of a high dose of androgens for somewhat a prolonged period of time.

Familial male pseudohermaphroditism due to C17-C20 desmolase deficiency

Three sibblings were seen for various degrees of abnormal sexual morphology. The first was stade II of Prader, the 2nd stade III, the third only had a bifid scrotum. In the two elder, basal levels (ng/d1) of 17αOH Progesterone (OHP), 17αOH Pregnenolone (Δ5OHP) and Progesterone (P) were 10-20 fold above normal while those of Testosterone (T), Δ4-androstenedione (Δ4), DHA and DHAS were low. None of these hormones including cortisol increased significantly under ACTH suggesting high endogenous ACTH levels. Dexamethasone (Dex) treatment suppressed all hormones. After hCG, T rose slightly (7 → 8 and 12 → 85) while OHP and Δ5OHP reached respectively 1065, 1050 and 662, 405 in each child. hCG + Dex confirmed the low T response (7 → 63 and 1 → 50 in the 2 children), abnormal increase of OHP (1 → 90 and 14 → 47), Δ5OHP (22 → 65 and 15 → 78). In the 2nd child after Fluoxymesterone P, OHP, Δ5OHP levels decreased to almost normal values while T, Δ4, DHA were unchanged. It is concluded that both testis and adrenals exhibit the enzyme defect. That the last newborn sibbling was also affected by the same defect was suggested on abnormally low levels of DHA (210) and T (15) and high levels of P (32156), OHP (1350) and Δ5OH (2382) at birth.

9 CRYPTORCHIDISM: COMPARISON OF 2 PROTOCOLS OF TREATMENT BY HUMAN CHORIONIC CONADOTROPIN (hCG)

It is Deneved that the positive action of hCG on cryptorchidism is mediated by the rise in endogenous testosterone (T). Previous studies have shown that plasma T rises steadily for 4-5 days (d.) after a single hCG injection (inj.). This study was undertaken to test the hypothesis that it is unnecessary to repeat inj. belore that peak. The proposed protocol (Rx) (I) consisted of 4 IM inj. of 100 IU/kg of hCG at 4 (n = 16) or 5 d. intervals (n = 79). Results, being similar, are given in the total group (I) (n = 95) and compared to that of a previous Rx (II) using 7 inj. of 1500 IU of hCG every 48 h (group II, n = 440). The % of unilateral (UC; 60%) and bilateral cryptorchidism (BC; 40%) was identical in both groups. Success (complete descent) was recorded in 50.9% of UC and 50% of BC in group I, and 40.7% of UC and 36.7% of BC in group II. Rate of relapse (at 1-4 yrs) was similar in group I (9%) and II (10%). Plasma T was measured respectively 4 and 1 d. after the last inj. in Rx I and II. Mean (±SD) T levels (ng/dl) were not different whether Rx was successful or not, either with Rx I (392 ± 207 and 430 ± 207) or II (495 ± 247 and 541 ± 304). In total groups, T levels were lower (p = 0.003) with Rx I (410 ± 207) than with Rx II (516 ± 273), possibly due to a relatively late time of sampling in Rx I. Finally, T values were normally distributed in Rx I but not in Rx II (median being respectively 384 and 443).In conclusion, a Rx using hCG at doses related to body size and inj. at only 4-5 day intervals appears as efficient, or even more, as Rx using frequent hCG injections in the treatment of undescended testis.

103 LONG-TERM FOLLOW UP OF 2 CASES OF MIXED GONADAL DYSGENESIS(MGD): TRAGIC CONSEQUENCES OF REARING IN MALE GENDER

Two boys, now 20 yr old, were seen at birth for ambigous genitalia(hypospadias stade III); only 1 gonad was palpated in an inguinal hernia; karyotypes were 46,XO/XY. At laparotomy, small vagina, uterus; one small testis on one side, a streak and a fallopian tube on the other side. In boy n°2 a gonocytoma was found in the streak. However, because at histology the testis appeared immature but normal, both were kept in the male gender. Streaks and Mullerian structures were removed. Both presented several of the classical somatic abnormalities observed in Turners syndrome and a very poor growth rate as well. At age 3, plasma testosterone(T) rose only to 415 and 220 ng/dl after hCG test. In both, plastic reconstruction of genitalia was difficult, particularly in boy n°2, with repetitive surgeries until age 10. In boy n°1, the testis progressively vanished, LH/FSH rose, gynecomastia developped, achievement of puberty required substitutive T Rx. At 19 yr, the testicular remnant was removed and 2 prostheses put in scrotum. In boy n°2, T rose to 730 ng/dl at 15 yr at the price of very high LH/FSH levels, but subsequently declined and substitutive T Rx needed at age 18.In conclusion, the choice of sex, made 20 yr ago at a time when MGD was about first recognized, was a mistake. Tragic results are 1) very short stature (final height 145 and 147 cms); 2) difficult and unsatisfactory reconstructive surgery; 3) a progressive vanishing testis and deficient Leydig and Sertoli cells functions suggesting that the apparently normal testis was also dysgenetic. Supported by INSERM grant (PRC 129047).

HLA and congenital 21-hydroxylase (21-OHD) deficiency : further evidence for a 21-OH locus between DR and GLO

Congenital adrenal hyperplasia (CAH) due to 21-OHD has been found to be closely linked to the major histocompatibility complex (MHC) and more specifically to HLA-B. A two gene model, one on either side of HLA-D has however been suggested by several authors. We report studies in a CAH family suggesting that the (or one of the two) 21-OH gene might be centromeric to D. The index patient presented ambiguous genitalia (stage III) but no clinical salt loss ; diagnosis was delayed and progressive virilization developped : at 3 yr 4/12, pubic hair, accelerated growth and bone maturation (5 yr). Diagnostic levels (ng/dl) of testosterone (163) and 17α -OH-progesterone (OHP) (basal = 28690 - 114,910 after ACTH) were found. Elevated baseline levels (ng/dl/h) of PRA (1563) further rose after Na restriction (2880) or ACTH (4900). The 3 brothers were clinically normal. HLA typing revealed the first to be heterozygous, the 2nd homozygous normal ; the 3rd was found to be HLA identical and MLC identical to the CAH-sister (A2CW6 B57 DR6/AW30 CW2 BW47 DR2). Microlymphocytotoxicity tests excluded any recombination between the A and D loci. Hormonal studies (baseline and ACTH stimulated levels of OHP, progesterone and cortisol) showed a typical heterozygote response in both the mother and brother n° 3. Unfortunately, studies of the red cell glyoxalase I (GLO) were not informative. However, a DR-GLO recombination is the likely explanation for the present findings, suggesting a 21-OH locus between DR and GLO loci.