Disorders of sex development

Disorders of sex development (DSD) occur in 1–2/10,000 live births, with a specific molecular diagnosis only possible in 20% of cases. Presentation is usually at birth, and gender assignment must be avoided before review by an expert multidisciplinary team. Initial investigations allow a working diagnosis to be made within 48 hr. In 46,XY DSD, surgery may be necessary to correct hypospadias, reposition or remove undescended testes, and remove symptomatic Müllerian remnants. In 46,XX DSD, feminizing surgery is performed less frequently than in the past, but genitoplasty may still be indicated. Psychosocial support is required to promote positive adaptation as gender dissatisfaction can occur in certain conditions. Long-term outcome data are sparse.     

Allele-specific PCR and Next-generation sequencing based genetic screening for Congenital Adrenal Hyperplasia in India

Genetic screening of Congenital Adrenal Hyperplasia (CAH) is known to be challenging due to the complexities in CYP21A2 genotyping and has not been the first-tier diagnostic tool in routine clinical practice. Also, with the advent of massive parallel sequencing technology, there is a need for investigating its utility in screening extended panel of genes implicated in CAH. In this study, we have established and utilized an Allele-Specific Polymerase Chain Reaction (ASPCR) based approach for screening eight common mutations in CYP21A2 gene followed by targeted Next Generation Sequencing (NGS) of CYP21A2, CYP11B1, CYP17A1, POR, and CYP19A1 genes in 72 clinically diagnosed CAH subjects from India. Through these investigations, 88.7% of the subjects with 21 hydroxylase deficiency were positive for eight CYP21A2 mutations with ASPCR. The targeted NGS assay was sensitive to pick up all the mutations identified by ASPCR. Utilizing NGS in subjects negative for ASPCR, five study subjects were homozygous positive for other CYP21A2 variants: one with a novel c.1274G>T, three with c.1451G>C and one with c.143A>G variant. One subject was compound heterozygous for c.955C>T and c.1042G>A variants identified using ASPCR and NGS. One subject suspected for a Simple Virilizing (SV) 21 hydroxylase deficiency was positive for a CYP19A1:c.1142A>T variant. CYP11B1 variants (c.1201-1G>A, c.1200+1del, c.412C>T, c.1024C>T, c.1012dup, c.623G>A) were identified in all six subjects suspected for 11 beta-hydroxylase deficiency. The overall mutation positivity was 97.2%. Our results suggest that ASPCR followed by targeted NGS is a cost-effective and comprehensive strategy for screening common CYP21A2 mutations and the CAH panel of genes in a clinical setting.     

235361例新生儿疾病筛查情况分析

目的调查黄冈市2016年1月1日—2019年6月30日新生儿遗传代谢性疾病的筛查结果。方法采用实时数据分析调查的方法,对黄冈市2016年1月1日—2019年6月30日出生并在黄冈市妇幼保健院进行遗传代谢病5项[先天性甲状腺功能减低症(CH)、苯丙酮尿症(PKU)、葡萄糖-6-磷酸脱氢酶(G6PD)缺乏症、先天性肾上腺皮质增生症(CAH)和地中海贫血]检测的235361例活产新生儿的结果及确诊数据进行分析和统计。结果2016年1月1日—2019年6月30日期间共筛查235361例新生儿,确诊CH患儿61例,发病率约为1:3858;确诊PKU患儿14例,发病率约为1:16812;确诊G6PD缺乏症(蚕豆病)患儿179例,发病率约为1:1315;确诊CAH患儿9例,发病率约为1:26151;确诊地中海贫血患儿446例,发病率约为1:528。结论黄冈市CH、PKU、G6PD缺乏症、CAH及地中海贫血发病率均低于全国平均发病率。加强健康教育和普及,通过分析质量控制指标加强质量管理,规范筛查流程,减少漏筛,提高召回确诊病例,不断提高服务质量。     

Transforming growth factor-β (TGF-β) pathway abnormalities in tenascin-X deficiency associated with CAH-X syndrome

Patients with congenital adrenal hyperplasia (CAH) with tenascin-X deficiency (CAH-X syndrome) have both endocrine imbalances and characteristic Ehlers Danlos syndrome phenotypes. Unlike other subtypes, tenascin-X-related Ehlers Danlos syndrome is caused by an extracellular matrix protein deficiency rather than a defect in fibrillar collagen or a collagen-modifying enzyme, and the understanding of the disease mechanisms is limited. We hypothesized that transforming growth factor-β pathway dysregulation may, in part, be responsible for connective tissue phenotypes observed in CAH-X, due to this pathway's known role in connective tissue disorders.Fibroblasts and direct tissue from human skin biopsies from CAH-X probands and age- and sex-matched controls were screened for transforming growth factor-β biomarkers known to be dysregulated in other hereditary disorders of connective tissue. In CAH-X fibroblast lines and dermal tissue, pSmad1/5/8 was significantly upregulated compared to controls, suggesting involvement of the bone morphogenetic protein pathway. Additionally, CAH-X samples compared to controls exhibited significant increases in fibroblast-secreted TGF-β3, a cytokine important in secondary palatal development, and in plasma TGF-β2, a cytokine involved in cardiac function and development, as well as palatogenesis. Finally, MMP-13, a matrix metalloproteinase important in secondary palate formation and tissue remodeling, had significantly increased mRNA and protein expression in CAH-X fibroblasts and direct tissue.Collectively, these results demonstrate that patients with CAH-X syndrome exhibit increased expression of several transforming growth factor-β biomarkers and provide a novel link between this signaling pathway and the connective tissue dysplasia phenotypes associated with tenascin-X deficiency.     

出生后采血时间对新生儿CAH筛查结果的影响分析

目的 探讨不同出生后采血时间对测定新生儿人群17-羟孕酮(17-OHP)筛查先天性肾上腺皮质增生症(CAH)的影响.方法 采用时间分辨荧光免疫分析方法,检测新生儿末梢血17-OHP浓度.分析不同出生后采血时间足月儿和早产儿中17-OHP水平.结果 出生后＜72hr和72～120hr,早产儿(＜37周)的17-OHP测定值均值都大于30nmol/L.出生后＜72hr、72-120hr,早产儿17-OHP测定值均高于足月儿.出生后72～120hr足月儿组的97th分位数为31.5nmol/L,早产儿组的97th分位数为62.9nmol/L.结论 采血时间对早产新生儿17-OHP测定筛查CAH有一定的影响,建议将出生后3～5天的早产儿的CAH筛查切割值设定为17-OHP＜60nmol/L较好,以减少假阳性率和召回率.     

麻疹减毒活疫苗治疗慢性活动性肝炎外周血IL－2和T细胞亚群的变化

用依赖白细胞介素Ⅱ（ＩＬ－２）的小鼠肿瘤细胞（ＣＴＬＬ）做为靶细胞，采用四甲基偶氮唑盐（ＭＴＴ）比色法，检测２０例慢性活动性肝炎（ＣＡＨ）、２０例正常献血员外周血ＩＬ－２水平，并以２０例ＣＡＨ患者为治疗对象，肌肉注射麻疹减毒活疫苗（ＭＶ），观察ＩＬ－２水平的动态变化，同时采用ＡＢＣ染色法测定外周血ＣＤ４＋、ＣＤ８＋，并与正常献血员ＩＬ－２、ＣＤ４＋、ＣＤ８＋进行比较：结果提示：ＣＡＨ患者中存在着明显的ＩＬ－２水平的低下及Ｔ淋巴细胞亚群比例的失衡，注射ＭＶ后可提高ＣＡＨ患者ＩＬ－２水平，改善Ｔ淋巴细胞亚群比例的失衡，以治疗３０天效果最明显。认为，ＭＶ对ＣＡＨ的作用可能是影响了细胞因子网络的某一环节，促进机体免疫功能的恢复。     

Geographic differences in HBV related,autoimmune, and cryptogenic chronic active hepatitis

ABSTRACT— To clarify the importance of ethnic and geographic factors in chronic active hepatitis (CAH), HBV markers and autoantibodies (AMA, ANA, SMA), have been compared in 158 patients with biopsy-proven CAH from New York City and in 92 patients with CAH from Milan. HBsAg-positive CAH was more frequently observed in Milan (49%) than in New York City (27%). However, among HBsAg-positive patients, HBcAg, HBeAg, and epidemiologic risk factors for acquisition of HBV infection were more frequently found in New York than in Italy. The prevalence of HBsAg-negative, anti-HBc-positive CAH and cryptogenic CAH was similar in the two cities, while autoimmune CAH was more frequently observed in New York (20%) than in Milan (2%). In particular, the prevalence of autoimmune hepatitis was higher among Jewish patients than among patients of Anglo-Saxon or Latin ethnic background in New York. Thus, environmental and/or ethnic factors may influence the prevalence of the four major types of CAH.     

Psychological adjustment in children and adults with congenital adrenal hyperplasia

OBJECTIVE: To determine psychological health in individuals with one form of intersexuality, congenital adrenal hyperplasia (CAH), and its relation to characteristics of the disease and treatment. STUDY DESIGN: Participants (ages 3-31 years) included 72 females and 42 males with CAH, and unaffected relatives (44 females and 69 males). Psychological adjustment was assessed with parent-reports on the Child Behavior Checklist (CBCL) and subject self-reports on the Self-Image Questionnaire for Young Adolescents (SIQYA) or the Multidimensional Personality Questionnaire (MPQ). Information about disease characteristics and genital surgery was obtained from medical records. RESULTS: There were no significant differences between females with CAH and unaffected females on any measure. Psychological adjustment was not significantly associated with genital virilization or age at genital surgery. Males with CAH were not significantly different from unaffected males in childhood, but they showed more negative affect at older ages. CONCLUSIONS: Psychological adjustment is not compromised in females with virilized genitalia who are treated early in life and reared as females. Adjustment does not appear to depend on the characteristics of the disease or its treatment, but sample size and restricted range limit generalizability about adjustment-disease associations.