Long-term cardiometabolic morbidity in young adults with classic 21-hydroxylase deficiency congenital adrenal hyperplasia

Purpose To study the current practice for assessing comorbidity in adults with 21-hydroxylase CAH and to assess the prevalence of comorbidity in these adults. Methods A structured questionnaire was sent to 46 expert centres managing adults with CAH. Information collected included current therapy and surveillance practice with a particular focus on osteoporosis/osteopaenia, hyperlipidaemia, type 2 diabetes/hyperinsulinaemia, hypertension, CV disease, obesity. Results Of the 31 (67%) centres from 15 countries that completed the survey, 30 (97%) screened for hypertension by measuring blood pressure, 30 (97%) screened for obesity, 26 (84%) screened for abnormal glucose homoeostasis mainly by using Hb1Ac (73%), 25 (81%) screened for osteoporosis mainly by DXA (92%), 20 (65%) screened for hyperlipidaemia and 6 (19%) screened for additional CV disease. Of the 31 centres, 13 provided further information on the six co-morbidities in 244 patients with a median age of 33 yrs (range 19, 94). Of these, 126 (52%) were females and 174 (71%) received fludrocortisone in addition to glucocorticoids. Of the 244 adults, 73 (30%) were treated for at least one comorbidity and 15 (21%) for more than 2 co-morbidities. Of 73, the patients who were treated for osteoporosis/osteopaenia, hyperlipidaemia, type 2 diabetes/hyperinsulinaemia, hypertension, CV disease, obesity were 43 (59%), 17 (23%), 16 (22%), 10 (14%), 8 (11), 3 (4%) respectively. Conclusion Cardiometabolic and bone morbidities are not uncommon in adults with CAH. There is a need to standardise the screening for these morbidities from early adulthood and to explore optimal therapy through routine collection of standardised data

Novel Mutations In Cyp11b1 Gene Leading To 11β-hydroxylase Deficiency In Brazilian Patients

Background: Deficiency of 11β-hydroxylase results in the impairment of the last step of cortisol synthesis. In females, the phenotype of this disorder includes different degrees of genital ambiguity and arterial hypertension. Mutations in the CYP11B1 gene are responsible for this disease. Objective: The objective of the study was to screen the CYP11B1 gene for mutations in two unrelated Brazilian females with congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Design: The coding and intron-exon junction regions of CYP11B1 were totally sequenced. A putative splice mutation was further investigated by minigene transcription. Results: We report two novel CYP11B1 mutations in these Brazilian patients. An Arabian Lebanese descendent female was found to be homozygous for a cytosine insertion at the beginning of exon 8, changing the 404 arginine to proline. It alters the open reading frame, creating a putative truncated protein at 421 residue, which eliminates the domain necessary for the association of heme prosthetic group. A severely virilized female was homozygous for the g.2791G>A transition in the last position of exon 4. This nucleotide is also part of 5′ intron 4 donor splice site consensus sequence. Minigene experiments demonstrated that g.2791G>A activated an alternative splice site within exon 4, leading to a 45-bp deletion in the transcript. The putative translation of such modified mRNA indicates a truncated protein at residue 280. Conclusions: We describe two novel mutations, g.4671-4672insC and g.2791G>A, that drastically affects normal protein structure. These mutations abolish normal enzyme activity, leading to a severe phenotype of congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Copyright © 2009 by The Endocrine Society.94934813485White, P.C., Curnow, K.M., Pascoe, L., Disorders of steroid 11β- hydroxylase isoenzymes (1994) Endocr Rev, 15, pp. 421-438White, P.C., Speiser, P.W., Congenital adrenal hyperplasia due to 21-hydroxylase deficiency (2000) Endocrine Reviews, 21 (3), pp. 245-291. , DOI 10.1210/er.21.3.245Mornet, E., Dupont, J., Vitek, A., White, P.C., Characterization of two genes encoding human steroid 11β-hydroxylase (P-450(11β)) (1989) Journal of Biological Chemistry, 264 (35), pp. 20961-20967Spoudeas, H.A., Slater, J.D., Rumsby, G., Honour, J.W., Brook, C.G., Deoxycorticosterone, 11β-hydroxylase and the adrenal cortex (1993) Clin Endocrinol, 39, pp. 245-251. , OxfHague, W., Honour, J., Malignant hypertension in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency (1983) Clin Endocrinol, 18, pp. 505-510. , OxfKrawczak, M., Cooper, D.N., The human gene mutation database (1997) Trends Genet, 13, pp. 121-122Chabre, O., Portrat-Doyen, S., Vivier, J., Morel, Y., Defaye, G., Two novel mutations in splice donor sites of CYP11B1 in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency (2000) Endocrine Res, 26, pp. 797-801Curnow, K.M., Slutsker, L., Vitek, J., Cole, T., Speiser, P.W., New, M.I., White, P.C., Pascoe, L., Mutations in the CYP11B1 gene causing congenital adrenal hyperplasia and hypertension cluster in exons 6, 7, and 8 (1993) Proc Natl Acad Sci USA, 90, pp. 4552-4556Skinner, C.A., Rumsby, G., Honour, J.W., Single strand conformation polymorphism (SSCP) analysis for the detection of mutations in the CYP11B1 gene (1996) Journal of Clinical Endocrinology and Metabolism, 81 (6), pp. 2389-2393. , DOI 10.1210/jc.81.6.2389De Carvalho, C.E., Castro, M., Moreira, A.C., De Mello, M.P., CYP11B1 mutation and polymorphisms in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency (1999) J Endocr Genet, 1, pp. 79-86Moreira, A.C., Elias, L.L.K., Pituitary-adrenal responses to corticotropin- releasing hormone in different degrees of adrenal 21-hydroxylase deficiency (1992) J Clin Endocrinol Metab, 74, pp. 198-203Mermejo, L.M., Elias, L.L.K., Marui, S., Moreira, A.C., Mendonca, B.B., De Castro, M., Refining hormonal diagnosis of type II 3β-hydroxysteroid dehydrogenase deficiency in patients with premature pubarche and hirsutism based on HSD3B2 genotyping (2005) Journal of Clinical Endocrinology and Metabolism, 90 (3), pp. 1287-1293. , DOI 10.1210/jc.2004-1552De-Araujo, M., Sanches, M.R., Suzuki, L.A., Guerra Jr., G., Farah, S.B., De-Mello, M.P., Molecular analysis of CYP21 and C4 genes in Brazilian families with the classical form of steroid 21-hydroxylase deficiency (1996) Brazilian Journal of Medical and Biological Research, 29 (1), pp. 1-13Soardi, F.C., Lemos-Marini, S.H.V., Coeli, F.B., Maturana, V.G., Silva, M.D., Bernardi, R.D., Justo, G.Z., De Mello, M.P., Heterozygosis for CYP21A2 mutation considered as 21-hydroxylase deficiency in neonatal screening (2008) Arq Bras Endocrinol Metab, 52, pp. 1388-1392White, P.C., Slutsker, L., Haplotype analysis of CYP11B2 (1995) Endocr Res, 21, pp. 437-442Ravichandran, K.G., Boddupalli, S.S., Hasemann, C.A., Peterson, J.A., Deisenhofer, J., Crystal structure of hemoprotein domain of P450BM-3, a prototype for microsomal P450's (1993) Science, 261 (5122), pp. 731-736Roumen, L., Sanders, M.P.A., Pieterse, K., Hilbers, P.A.J., Plate, R., Custers, E., De Gooyer, M., Hermans, J.J.R., Construction of 3D models of the CYP11B family as a tool to predict ligand binding characteristics (2007) Journal of Computer-Aided Molecular Design, 21 (8), pp. 455-471. , DOI 10.1007/s10822-007-9128-9Mount, S.M., A catalogue of splice junction sequences (1982) Nucleic Acids Res, 10, pp. 459-472Buratti, E., Chivers, M., Královicová, J., Romano, M., Baralle, M., Krainer, A.R., Vorechovsky, I., Aberrant 5′ splice sites in human disease genes: Mutation pattern, nucleotide structure and comparison of computational tools that predict their utilization (2007) Nucleic Acids Res, 35, pp. 4250-426

A Single Nucleotide Variant In The Promoter Region Of 17β-hsd Type 5 Gene Influences External Genitalia Virilization In Females With 21-hydroxylase Deficiency

In 21-hydroxylase deficiency (21-OHD), there is an influence of genotype on the severity of external genitalia virilization. However, females carrying mutations predicting a similar impairment of enzymatic activity present a wide variability of genital phenotypes. In such cases, interindividual variability in genes related to the sex steroid hormone pathway could play a role. Objective: To evaluate the influence of POR, HSD17B5 and SRD5A2 variants on the severity of external genitalia virilization in 21-OHD females. Design and Patients: Prader stages were evaluated in 178 females with 21-OHD from a multicenter study. The 21-OHD genotypes were divided into two groups according to their severity: severe and moderate. The influences of the POR p.A503V, HSD17B5 c.-71A>G, HSD17B5 c.-210A>C, and SRD5A2 p.A49T and p.V89L variants on the degree of external genitalia virilization were analyzed. Results: The POR p.A503V, HSD17B5 c.-71A>G, HSD17B5 c.-210A>C, and SRD5A2 p.A49T and p.V89L variants were found in 25, 33, 17, 1, and 31% of the alleles, respectively. In uni- and multilinear regression, HSD17B5 c.-210A>C has a significant influence on the degree of external genitalia virilization. This variant was also identified with a higher frequency in the most severely virilized females. Conclusion: We demonstrated that a variant in the promoter region of HSD17B5 related to fetal androgen synthesis influences the genital phenotype in 21-OHD females. © 2016 S. Karger AG, Basel.85533333

21-Hydroxylase deficiency in Brazil

We determined the frequency of large rearrangements and point mutations in 130 Brazilian patients with 21-hydroxylase deficiency and correlated genotype with phenotype. The frequency of CYP21 deletions was lower (4.4%) than in most of the previous series described, whereas the frequency of large gene conversions was similar to the frequency reported in the literature (6.6%). The most frequent point mutations were I2 splice (41.8% in salt wasting - SW), I172N (32.6% in simple virilizing - SV) and V281L (40.2% in the late onset form - LO). The frequency of the nine most common point mutations was similar to that reported for other countries. The 93 fully genotyped patients were classified into 3 mutation groups based on the degree of enzymatic activity (A<2%, B <FONT FACE="Symbol">@</FONT> 2%, C>20%). In group A, 62% of cases presented the SW form; in group B, 96% the SV form, and in group C, 88% the LO form. We diagnosed 80% of the affected alleles after screening for large rearrangements and 15 point mutations. To diagnose these remaining alleles we sequenced the CYP21 gene of one patient with the SV form and identified a heterozygous G->A transition in codon 424. This mutation leads to a substitution of glycine by serine in a conserved region and was also found in a compound heterozygous state in 4 other patients. The mutation G424S presented a linkage disequilibrium with CYP21P and C4A gene deletions and HLA DR17, suggesting a probable founder effect. Search for the G424S mutation in other populations will reveal if it is restricted to the Brazilian patients or if it has a wider ethnic distribution

Analysis of therapy monitoring in the International Congenital Adrenal Hyperplasia Registry

Objective Congenital adrenal hyperplasia (CAH) requires exogenous steroid replacement. Treatment is commonly monitored by measuring 17-OH progesterone (17OHP) and androstenedione (D4). Design Retrospective cohort study using real-world data to evaluate 17OHP and D4 in relation to hydrocortisone (HC) dose in CAH patients treated in 14 countries. Patients Pseudonymized data from children with 21-hydroxylase deficiency (21OHD) recorded in the International CAH Registry. Measurements Assessments between January 2000 and October 2020 in patients prescribed HC were reviewed to summarise biomarkers 17OHP and D4 and HC dose. Longitudinal assessment of measures was carried out using linear mixed-effects models (LMEM). Results Cohort of 345 patients, 52.2% female, median age 4.3 years (interquartile range: 3.1–9.2) were taking a median 11.3 mg/m2/day (8.6–14.4) of HC. Median 17OHP was 35.7 nmol/l (3.0–104.0). Median D4 under 12 years was 0 nmol/L (0–2.0) and above 12 years was 10.5 nmol/L (3.9–21.0). There were significant differences in biomarker values between centres (p < 0.05). Correlation between D4 and 17OHP was good in multiple regression with age (p < 0.001, R2 = 0.29). In longitudinal assessment, 17OHP levels did not change with age, whereas D4 levels increased with age (p  0.05). Multivariate LMEM showed HC dose decreasing by 1.0 mg/m2/day for every 1 point increase in weight standard deviation score. Discussion Registry data show large variability in 17OHP and D4 between centres. 17OHP correlates with D4 well when accounting for age. Prescribed HC dose per body surface area decreased with weight gain