Marumudi Eunice

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.

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

Gender Identity of Children and Young Adults with 5α-Reductase Deficiency

Male pseudohermaphroditism (46,XY DSD) due to 5alpha-reductase deficiency has been recognized for the last few decades. There is scant literature on this entity in India. We compiled data on five patients with this disorder. Four of our five patients were reared as females. Our assessment of these children reveals that they had male gender identity from childhood. Three of the four reared as females chose to change gender role at adolescence, while the fourth is still prepubertal. We conclude that all these patients had male gender identity from early childhood. The parents took note of this only after the appearance of male secondary sexual characteristics at puberty, thereby giving an impression of change in gender identity and gender role.

Congenital adrenal hyperplasia: Results of medical therapy on appearance of external genitalia.

OBJECTIVE Girls with congenital adrenal hyperplasia show a variable degree of genital masculinization at birth. Antenatal dexamethazone treatment for the mother is known to reduce the severity of this condition. There are however few data on the effect of postnatal steroid therapy on the cosmetic appearance of the external genitalia. PATIENTS AND METHOD We report the appearance of the external genitalia of three girls with classical congenital adrenal hyperplasia followed up by steroid therapy alone. RESULTS Growth of the labia majora and a relative reduction in clitoral size improved the appearance of the external genitalia in these three girls. CONCLUSION There seems to be improvement in the external appearance of genitalia with postnatal steroid therapy. This could allay parental concerns and help in the planning of corrective surgery peripubertally with the informed consent of the child.

Phenotype, hormonal profile and genotype of subjects with partial androgen insensitivity syndrome: report of a family with four adult males and one child with disorder of sexual differentiation

There is little information on the molecular basis of intrafamilial and inter‐familial phenotypic heterogeneity with the same androgen receptor (AR) mutation in patients with partial androgen insensitivity syndrome. A genetic analysis was performed in a large kindred with ambiguous genitalia and the genotype–phenotype correlations were analysed. The index case was brought for sex assignment. Family history revealed four other affected members who had hypospadias and varying degrees of virilisation. All the affected males had hemizygous mutations in the third exon of the AR gene (A596T). One was also found to have a heterozygous mutation in the fourth exon of the 5 alpha reductase type 2 gene (G196S). This affected male with double mutations was better virilised compared with the other affected members with a single mutation. The degree of virilisation correlated with serum testosterone levels. Gynaecomastia was not present in any of these subjects. It is concluded that the subject with dual gene defects also had higher levels of testosterone and pubertal virilsation. Testosterone levels possibly govern the degree of pubertal virilisation in subjects with A596T gene defects. It is not clear whether the better pubertal virilsation and higher testosterone are in any way causally related to the SRD5A2 gene defect.

Pubertal development among girls with classical congenital adrenal hyperplasia initiated on treatment at different ages.

Introduction: Children with congenital adrenal hyperplasia (CAH) provide us an opportunity to study the clinical effects of androgen excess in humans. We studied the sequence of pubertal development in girls with congenital adrenal hyperplasia initiated on treatment at different ages, to assess the effects of androgen exposure on the Hypothalamic-Pituitary-Ovarian (HPO) axis. Materials and Methods: Girls more than 18 years of age, with CAH, on follow-up at this hospital were the subjects for this study. Details of history, physical findings, laboratory evaluation, and medication were noted from their case records and verified from the patients and their / parents, in addition to assessment of their present health status. Result: We studied 24 patients of classical CAH (SW-2, SV-22, average age – 24.5 ± 6.6 years). All had varying degrees of genital ambiguity (Prader stage 3 (n = 13), Prader stage 2 (n = 10), Prader stage 1 (n = 1). Among them were13 girls, who were started on steroids after eight years of age. Girls who received treatment from infancy and early childhood had normal pubertal development (mean age at menarche 11.4 ± 1.7 years). Hirsutism was not a problem among them. Untreated children had progressive clitoral enlargement throughout childhood, developed pubic hair at around three to six years of age, and facial hair between nine and eleven years. Plasma testosterone ranged from 3 to 6 ng / ml prior to treatment. Six of the 13 untreated CAH girls had subtle breast development starting at ages 11 – 16 years and three had spontaneous infrequent vaginal bleeding starting at ages 11 – 17. Steroid supplementation initiated pubertal changes in older girls in two-to-six months’ time. Conclusion: There was a delay in HPO axis maturation (as evidenced by delayed pubertal development) in the absence of treatment in girls with CAH. This could be corrected with steroid supplementation.

Phenotype, genotype and gender identity in a large cohort of patients from India with 5α-reductase 2 deficiency.

Deficiency of the 5α‐reductase 2 enzyme impairs the conversion of testosterone to dihydrotestosterone (DHT) and differentiation of external genitalia, seminal vesicles and prostate in males. The present study describes the phenotype, genotype and gender identity in a large cohort of patients with 5αRD2. All patients underwent detailed clinical evaluation, hormonal profile, karyotyping and molecular analysis of the SRD5A2 gene. The molecular analysis of the SRD5A2 gene showed the presence of mutant alleles in 24 patients. We found 6 novel mutations IVS(1‐2) T>C, p.A52T, 188‐189insTA, 904‐905ins A, p.A12T and p.E57X in our patients. All patients had ambiguous genitalia and the degrees of under‐virilization ranged from penoscrotal hypospadias and microphallus to clitoromegaly. The position of gonads was variable in patients with same mutation. All the patients with mutations in the SRD5A2 gene had male gender identity. Those reared as female had gender dysphoria and underwent gender reassignment. Though a specific genotype–phenotype correlation could not be established in our patient but confirming the diagnosis of 5αRD2 with assessment of the SRD5A2 gene may help in appropriate gender assignment.

The effect of growth hormone deficiency on size-corrected bone mineral measures in pre-pubertal children.

SummaryGrowth hormone deficiency (GHD) in children has been frequently perceived to be a cause of low bone mass accrual. The confounding effects of poor growth limit the interpretation of prior studies of bone health in GHD. We studied size-corrected bone mineral measures in 30 pre-pubertal GHD children and 75 healthy controls. Our study shows that size-corrected whole-body bone mineral content of GHD children were comparable with controls.IntroductionThe purpose of this study is to evaluate the effects of GHD on size-corrected bone measures at the lumbar spine (LS) and the whole body (WB).MethodsLS bone area (BA), LS bone mineral content (BMC), WB BA, WB BMC, and lean body mass (LBM) were measured in 30 pre-pubertal GHD children and 75 controls by dual-energy X-ray absorptiometry. Multiple linear regressions were used to calculate size-corrected (Sc) LS BASc, LS BMCSc, WB BASc, and WB BMCSc from control subjects using height and age as independent variables. Furthermore, the relationship between muscle and bone was studied by first assessing LBM for height (LBMHt) and then determining WB BMC for LBM (WB BMCLBM). All values were converted to Z-scores and compared with the control.ResultsAt diagnosis, WB BMCSc Z-score of GHD children was not significantly different from controls. However, mean Z-scores of LS BASc (−0.89 ± 0.84, p < 0.0001), LS BMCSc (−0.70 ± 1.1, p < 0.001), WB BASc (−0.65 ± 1.0, p < 0.006), and LBMHt (−0.66 ± 1.7, p < 0.01) were significantly reduced, and WB BMCLbm (0.78 ± 1.5, p < 0.003) was significantly higher in GHD children than controls.ConclusionSize-corrected WB BMC of GHD children were comparable with controls, and bones were normally adapted for muscle mass. Determinants of bone strength which may primarily be affected by GHD are muscle mass, bone size, and geometry rather than bone mass.

Mother-to-Son Transmission of a Luteinizing Hormone Receptor Activating Mutation in a Prepubertal Child with Testotoxicosis

AIM To identify the LHR gene mutation in a prepubertal child with testotoxicosis. METHODS Standard RIA procedure was used for estimating LH, FSH and testosterone levels. Molecular analysis was done by standard PCR using different sets of primers and reaction conditions specific for the LHR gene. Direct sequencing was done using the ABI Prism Dye terminator sequencing kit and the ABI 310 sequencing apparatus. RESULTS We found a heterozygous mutation of the LHR gene in exon 11 of the second transmembrane region, Met-->Thr at the 398 position (M398T). The same mutation was also found in the probands mother. CONCLUSION To our knowledge, this is the first molecular characterization of maternally inherited testotoxicosis in a 5 1/2-year-old boy from the Indian subcontinent.