Prenatal dexamethasone treatment for classic 21-hydroxylase deficiency in Europe

Dexamethasone; PrenatalDexametasona; PrenatalDexametasona; PrenatalObjective To assess the current medical practice in Europe regarding prenatal dexamethasone (Pdex) treatment of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Design and methods A questionnaire was designed and distributed, including 17 questions collecting quantitative and qualitative data. Thirty-six medical centres from 14 European countries responded and 30 out of 36 centres were reference centres of the European Reference Network on Rare Endocrine Conditions, EndoERN. Results Pdex treatment is currently provided by 36% of the surveyed centres. The treatment is initiated by different specialties, that is paediatricians, endocrinologists, gynaecologists or geneticists. Regarding the starting point of Pdex, 23% stated to initiate therapy at 4–5 weeks postconception (wpc), 31% at 6 wpc and 46 % as early as pregnancy is confirmed and before 7 wpc at the latest. A dose of 20 µg/kg/day is used. Dose distribution among the centres varies from once to thrice daily. Prenatal diagnostics for treated cases are conducted in 72% of the responding centres. Cases treated per country and year vary between 0.5 and 8.25. Registries for long-term follow-up are only available at 46% of the centres that are using Pdex treatment. National registries are only available in Sweden and France. Conclusions This study reveals a high international variability and discrepancy in the use of Pdex treatment across Europe. It highlights the importance of a European cooperation initiative for a joint international prospective trial to establish evidence-based guidelines on prenatal diagnostics, treatment and follow-up of pregnancies at risk for CAH.This work was supported by the Deutsche Forschungsgemeinschaft (Heisenberg Professorship, 325768017 to N R and 314061271-TRR205 to N R and A H), the European Commission for funding EndoERN CHAFEA FPA grant no. 739527, the Eva Luise und Horst Köhler Stiftung & Else Kröner-Fresenius-Stiftung (2019_KollegSE.03 to H N) and the Stockholm County Council (Senior clinical research fellowship dnr RS 2019-1140 to S L), Stiftelsen Frimurare Barnhuset i Stockholm and Lisa and Johan Grönbergs Stiftelse

Aberrant Splicing Is the Pathogenicity Mechanism of the p.Glu314Lys Variant in CYP11A1 Gene

Context: The cholesterol side chain cleavage enzyme (CYP11A1) catalyzes the conversion of cholesterol to pregnenolone, the first rate-limiting step of steroidogenesis. CYP11A1 mutations are associated with primary adrenal insufficiency (PAI) as well as disorders of sex development (DSD) in 46,XY patients.Objective: To define the pathogenicity mechanism for the p.Glu314Lys variant, previously reported, and found in four additional patients with CYP11A1 deficiency.Subjects and Methods: DNA of four patients presenting with delayed PAI and/or 46,XY DSD were studied by Sanger or Massively Parallel sequencing. Three CYP11A1 mutations were characterized in vitro and in silico, and one by mRNA analysis on testicular tissue.Results: All patients were compound heterozygous for the previously described p.Glu314Lys variant. In silico studies predicted this mutation as benign with no effect on splicing but mRNA analysis found that it led to incomplete exon 5 skipping. This mechanism was confirmed by minigene experiment. The protein carrying this mutation without exon skipping should conserve almost normal activity, according to in vitro studies. Two other mutations found in trans, the p.Arg120Gln and p.Arg465Trp, had similar activity compared to negative control, consistent with the in silico studies.Conclusions: We provide biological proof that the p. Glu314Lys variant is pathogenic due to its impact on splicing and seems responsible for the moderate phenotype of the four patients reported herein. The present study highlights the importance of considering the potential effect of a missense variant on splicing when it is not predicted to be disease causing

Quel conseil génétique dans les formes non classiques de déficit en 21-hydroxylase ? (étude de 119 cas : intérêt du dépistage des conjoints pour la prévention de l'ambiguïté sexuelle des foetus féminins atteints de forme classique)

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Le Déficit en 21-hydroxylase (mise au point de l'exploration moléculaire de 1538 patients et 188 hétérozygotes ; corrélations génotype-phénotype)

Ce travail a été réalisé chez 1538 patients atteints de déficit en 21-hydroxylase (966 formes classiques, 566 formes non classiques et 6 formes intermédiaires) et 188 hétérozygotes.L'exploration moléculaire du gène CYP21 a exigé une importante mise au point technique, avec comme difficulté l'existence d'un pseudogène homologue et à l'origine des lésions identifiées en pathologie ; elle a conduit à une véritable stratégie d'exploration basée sur le séquençage du gène par étapes, jusqu'à sa totalité si nécessaire. Le génotype a été identifié chez 99 % des patients et une mutation trouvée chez 172 hétérozygotes. Nous avons découvert une soixantaine de nouvelles mutations, dont une anomalie de la région 5' régulatrice, ainsi qu'une nouvelle conversion génique de l'extrémité 5'. Une étude complémentaire de microsatellites extra-géniques a été développée. L'analyse des données clinico-biologiques des patients et la confrontation aux résultats génétiques ont confirmé l'existence de corrélations génotype-phénotype chez la quasi-totalité d'entre eux, à condition d'une exploration rigoureuse et complète du gène. Les critères diagnostiques des formes classiques et non classiques ont été confirmés avec l'importance d'une étude génétique dans les cas douteux. Le dépistage des hétérozygotes basé le dosage du 21-désoxycortisol sous ACTH a été validé par la biologie moléculaire. Cette étude a permis la mise en place d'un réseau national pour la prise en charge du déficit en 21-hydroxylase. Elle souligne que l'étude du gène CYP21 est capitale chez les patients et leur famille ainsi que les hétérozygotes dépistés : l'identification des sujets porteurs d'une lésion sévère est la base d'un conseil génétique fiable.LYON1-BU Santé (693882101) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

Optimized nested PCR enhances biological diagnosis and phylogenetic analysis of human parvovirus B19 infections

International audienceDiagnosis and epidemiological analysis of human parvovirus B19 (hB19V) infections are essential for disease management in severely ill patients. This study aimed to evaluate the performance of an optimized NS1-VP1u nested PCR for detection and sequencing of viruses in clinical samples using 224 clinical and five reference samples. PCR sensitivity, specificity, and positive and negative predictive values were perfect (100%). While phylogenetic analysis of a 615 bp-long fragment demonstrated that the viruses in all of the samples belonged to genotype 1, this study confirmed that this optimized PCR could detect all known hB19V with high performance

New management strategy of pregnancies at risk of congenital adrenal hyperplasia using fetal sex determination in maternal serum: French cohort of 258 cases (2002-2011)

International audienceCONTEXT: Prenatal dexamethasone (DEX) treatment has been proposed since 1984 to prevent genital virilization in girls with congenital adrenal hyperplasia (CAH). DEX is effective in CAH females if initiated before the sixth week of gestation, but its safety in children treated in utero remains controversial regarding cognitive functions.OBJECTIVE: To avoid prenatal DEX in males and initiate DEX in due time in CAH females, we proposed in 2002 a protocol for fetal sex determination in the maternal serum (SRY test).DESIGN AND SETTING: We conducted a retrospective study of the management of 258 fetuses in the period 2002 through 2011 in pregnancies managed in referent medical centers with an institutional practice. PATIENTS: A total of 258 fetuses at risk of CAH (134 males and 124 females) were included.INTERVENTION: DEX was offered after informed consent to pregnant women. MAIN OUTCOME MEASURE: The sensitivity of an early SRY test was evaluated after data collection.RESULTS: The SRY test is sensitive from 4 weeks and 5 days of gestation. It avoided prenatal DEX in 68% of males, and this percentage increased over the years. DEX was maintained until prenatal diagnosis in non-CAH females. Virilization was prevented in 12 CAH girls treated at the latest at 6 weeks gestation and minimized in 3 girls treated between 6 and 7 weeks gestation. Maternal tolerance was correct. No fetal malformations were noted in the 154 children treated in utero.CONCLUSIONS: The SRY test is reliable to avoid prenatal DEX in males, but its application must be improved. Prenatal DEX should be maintained to prevent virilization and traumatic surgery in CAH girls after informed consent and information provided to families about the benefit to risk ratio in limiting hyperandrogenism during fetal life. Our large multicentric French cohort has helped to better assess the risks previously reported

The experience of diagnosis announcement in rare endocrine diseases: a survey of the French FIRENDO network

International audienceContextDiagnosis announcement of a chronic disease is a crucial moment for patients as well asfor their families and an important step in the management of severe conditions such asrare endocrine diseases. Little is known of how diagnosis is communicated to patients andfamilies. The FIRENDO network was created by the third French Plan for Rare Diseases,to promote autonomy, care and research on rare endocrine diseases.ObjectivesThe aim of this study was to characterize, for the first time, the experience and needs ofpatients and/or their parents around the announcement of diagnosis to ensure optimalquality of care.MethodsA quantitative self-administered survey on diagnosis announcement procedures in rareendocrine diseases was launched in April 2017 by the ad hoc FIRENDO thematic workinggroup in collaboration with its 11 partnering patient associations and support groups. Thequestionnaire was designed and revised by patient support group representatives, adultand pediatric endocrinologists, psychologists and biologists, all expert in rare endocrinediseases. It was made available on the FIRENDO network website and distributed mainlyby email with electronic links on their respective websites to members of all affiliatedpatient support groups.ResultsPage 3 of 24Journal Pre-proofQuestionnaires were filled out by 391 patients and 223 parents (median age of patients: 39years). The following conditions were associated with at least 30 answers: Addison’sdisease, classical forms of congenital adrenal hyperplasia (CAH), Russell-Silversyndrome, Cushing’s syndrome, acromegaly and craniopharyngioma. Overall, someannouncement modalities were judged favorably by patients: physician’s empathy,availability and use of clear terms, and presence of family at the time of announcement.However, a lack of psychological care and information documents was reported, as well assome inadequate procedures such as postal mail announcements.ConclusionThis work suggests that better knowledge of the patient’s experience is useful forimproving the diagnosis announcement of rare endocrine disorders. The mainrecommendations derived from the survey were the need for several announcement visits,information on patient support groups and reference centers, imperatively avoidingimpersonal announcement, and the usefulness of a written accompanying document

Clinical Outcome, Hormonal Status, Gonadotrope Axis, and Testicular Function in 219 Adult Men Born With Classic 21-Hydroxylase Deficiency. A French National Survey

International audienceContext: Outcomes of congenital adrenal hyperplasia due to classic 21-hydroxylase deficiency (21OHD) have been widely studied in children and women, but less so in men.Objective: The objective was to analyze data from a network of metropolitan French teaching hospitals on the clinical outcome of classic 21OHD in a large sample of congenital adrenal hyperplasia/21OHD-genotyped adult men, and particularly the impact of 21OHD on the gonadotrope axis, testicular function, and fertility.Methods: From April 2011 to June 2014, tertiary endocrinology departments provided data for 219 men with 21OHD (ages, 18-70 y; 73.6% salt wasters, 26.4% simple virilizers). Testicular sonography was performed in 164 men, and sperm analysis was performed in 71 men.Results: Mean final height was 7.8 cm lower than in a reference population. Obesity was more common, and mean blood pressure was lower than in the reference population. None of the patients were diabetic, and lipid status was generally normal. Blood electrolyte status was normal in the vast majority of men, despite markedly elevated ACTH and renin levels. Serum progesterone, 17-hydroxyprogesterone, and androstenedione levels were above normal in the vast majority of cases. Hormonal profiling variously showed a normal gonadotrope-testicular axis, gonadotropin deficiency, or primary testicular insufficiency. Testicular sonography revealed testicular adrenal rest tumors (TARTs) in 34% of 164 men. Serum inhibin B and FSH levels were significantly lower and higher, respectively, in patients with TARTs. Severe oligospermia or azoospermia was found in 42% of patients and was significantly more prevalent in men with TARTs (70%) than in men with normal testes (3.6%; P < .0001). Among men living with female partners, TARTs were significantly more prevalent in those who had not fathered children.Conclusion: We report the spectrum of testicular/gonadotrope axis impairment in the largest cohort of 21OHD men studied to date. Our results suggest that French men with 21OHD managed in specialized centers frequently have impaired exocrine testicular function but that its reproductive implications are often overlooked