J Pediatr Endocr Met 2015; aop
Nasir A.M. Al-Jurayyan, Sharifah D.A. Al Issa, Abdulrahman M.H. Al Nemri, Hessah M.N. Al Otaibi and Amir M.I. Babiker*
The spectrum of 46XY disorders of sex development in a University centre in Saudi Arabia Abstract Background: The term disorders of sex development (DSD) includes congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical. The spectrum of the 46XY (DSD) is so broad. In this study, we reviewed the clinical spectrum of a cohort of patients with 46XY DSD in a tertiary institute in the Middle East over two decades. Objective: To define the clinical spectrum of 46XY DSD in a major teaching hospital, Riyadh, Saudi Arabia. Materials and methods: This is a retrospective, case series hospital-based study. The case notes, laboratory investigations, and imaging studies were reviewed for patients with 46XY DSD over a 20 years period (1989–2010) at King Khalid University Hospital, Riyadh, Saudi Arabia. Molecular genetics were not available in all patients. Results: During the period under review; a total of 56 patients were seen with 46XY DSD due to variable etiologies. Androgen insensitivity syndromes (AIS) and 5-α-reductase deficiency were among the commonest (44.6%), with multiple siblings involvement within the family. Of these, 16 patients were showing variable degrees of insensitivity ranging between complete (n = 5, 31.2%) and partial (n = 11, 68.8%) insensitivity, whereas in nine patients the diagnosis of 5-α-reductase deficiency was entertained based on hormonal studies. Of interest to see was a high number of patients (n = 14, 25%) either with a localized congenital anomalies such as the cloacal anomalies or generalized congenital malformations following the pattern of certain syndromes. *Corresponding author: Dr. Amir M.I. Babiker, FRCPCH (UK), Department of Pediatrics (39), College of Medicine and KKUH, P.O. Box 2925, Riyadh 11461, Saudi Arabia, Phone: +966-537806560, Fax: +966-114679463, E-mail: [email protected]; [email protected] Nasir A.M. Al-Jurayyan, Sharifah D.A. Al Issa, Abdulrahman M.H. Al Nemri and Hessah M.N. Al Otaibi: Department of Pediatrics, College of Medicine and King Khalid University Hospital (KKUH), King Saud University, Riyadh, Saudi Arabia
Conclusion: A wide spectrum of causes were noted. Androgen insensitivity syndrome was the commonest. In Saudi Arabia, where consanguineous mating is high, 5-α-reductase is also a common cause of 46XY DSD. Keywords: ambiguous genitalia; DSD; Saudi Arabia; spectrum; 46XY. DOI 10.1515/jpem-2014-0503 Received December 5, 2014; accepted April 2, 2015
Introduction Normal male sexual differentiation is a complex mechanism, depending on genetic and hormonal control. The bipotential gonad arises at the genital ridge under the control of autosomal genes which are also involved in the formation of other organs. Progression toward testicular differentiation is mediated through both autosomal and some specific genes, leading to alignment of Sertoli cells and Leyding cells. Within the latter, androgen formation is induced by human chorionic gonadotrophin (hCG) and luteinizing hormones (LH). The influence of testosterone and dihydrotestosterone leads to differentiation of epidydimis, vas deferens, prostate, and external genitalia. Androgens mediate their action through the androgen receptor, a nuclear transcription factor controlling the regulation of so far the unknown target genes. Genetic variations within the pathway interrupt normal male development and will lead to malformation of the external and or internal genitalia (1–6). Steroidogenic factor 1 (SF1, NR5A1) is currently a key transcriptional regulator of genes involved in the hypothalamic-pituitary-gonadal axis and SF1 mutations were found to be a frequent cause of 46XY disorders of sex development (DSD) (7). Yet, the investigation for SF1 mutation was not performed in our patients in this study. The spectrum of 46XY DSD is so broad and characterized by incomplete intrauterine masculinization, and the
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2 Al-Jurayyan et al.: The spectrum of 46XY disorders of sex development presence or absence of Mullerian structures. Complete absence of virilization resulting in a normal female external genitalia can result from gonadotrophin deficiency, testosterone biosynthesis, or action defects or abnormalities of gonadal development (8). These patients generally seek medical attention at pubertal age, due to the absence of breast development and/or primary amenorrhea (8–12). The psychological and social implications of gender assignment require a multi-disciplinary approach and an experienced team which includes a geneticist, neonatologist, endocrinologist, psychiatrists, pediatric surgeon, or pediatric urologist and social workers (13, 14). This study aims to highlight and express the importance of considering the various causes in the differential diagnosis. It is one of the first reports on a longitudinal data from Saudi Arabia highlighting the spectrum of such a rare, yet socially and medically important condition, which requires careful medical attention.
Materials and methods The study population consisted all patients presented to the pediatric endocrine and pediatric clinics, King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia over a 20-year period (1989–2010). King Khalid University Hospital is one of the main referral hospitals in Riyadh City and considered as the main teaching hospital for King Saud University. The hospital provides primary, secondary, and tertiary health care services for the local population and also receives patients referral from all over the country. Reviewing the clinical notes of patients with 46XY DSD in the study population, in retrospect, ambiguous genitalia was considered when there was difficulty in determining the sex of patient on initial examination or when the external genitalia showed significant structural deviation from normal in an apparent male or female. The appropriate diagnostic (radiological and serological) evaluation were performed for all patients in the study (2). Routine tests included karyotype, follicular stimulating hormone (FSH), LH, testosterone (T), estradiol, adrenal androgens, serum electrolytes, urinalysis, and abdominal and pelvic ultrasounds. Additional tests, as clinically indicated, included 17 hydroxyprogestrone, dihydrotestosterone (DHT), renal fuction tests, and renal ultrasound when there was suspected associated renal impairment. Laparoscopy and gonadal biopsy were performed when appropriate; however, none of them showed evidence of gonadoblastoma. The following criteria were used to support the diagnosis of 5-α-reductase: karyotype 46XY, T:DHT ratio of > 10 as baseline and > 20 post hCG injections, other hormonal tests that help in ruling out other differential diagnoses and absence of female organs, not as in androgen insensitivity syndrome (AIS), in pelvic ultrasound scan. Both T, which was tested locally, and DHT, which was tested in different labrotaries in Europe and America, were assessed by radioimmunoassay. T was evaluated at basal levels in all patients, and in all prepubertal patients following an hCG stimulation test (1500 IU of hCG given by intramuscular injections) for 3 consecutive days
on an outpatient basis. Venous samples were taken before the test and approximately 24 h after the 3rd hCG injection. All patients were managed by an experienced multidisciplinary team.
Results During the period under review; a total of 56 patients were seen with 46XY DSD due to variable etiologies. AIS and 5-α-reductase deficiency were among the commonest (44.6%), with multiple siblings involvement within the family (three families of 5-α-reductase deficiency in our series). Of these, 16 patients were showing variable degrees of insensitivity ranging between complete (n = 5, 31.2%) and partial (n = 11, 68.8%) insensitivity, while in nine patients the diagnosis of 5-α-reductase deficiency was entertained based on hormonal studies. Molecular genetics were not available in all patients in this retrospective study. Of interest to see was a high number of patients (n = 14, 25%) either with a localized congenital anomalies, such as the cloacal anomalies or generalized congenital malformations following the pattern of certain syndromes. Laparoscopy and gonadal biopsies were performed when appropriate and it did not reveal gonadoblastoma in any of our patients.
Discussion The spectrum of causes of 46XY DSD is so broad (Table 1). To elucidate the cause can be time consuming and sometimes difficult. In addition to radiological studies, specific diagnostic tests including genetic and hormonal studies and therapeutic trials should be obtained (8–12). Previously called male pseudohermaphrodite, 46XY DSD, can result either from disorders of testicular development or in androgen synthesis or action. Male gonads are palpable in the majority of 46XY DSD patients. Abnormalities in the expression of genes involved in the cascade of testis determination can cause anomalies of gonads development (complete or partial forms of gonadal dysgenesis with or without syndromic phenotype, ovotesticular DSD, testicular regression syndrome). Mutation in certain genes (WT1) results in Denys-Drash syndrome or Fraiser syndrome. Complete gonadal dysgenesis (Swyer syndrome) with a female phenotype with a full development of Mullerian structures, and streak of gonads. Leydig cell aplasia or hypoplasia, due to abnormalities in hCG/ LH receptor and testosterone biosynthesis defect (STAR) deficiency, P450 SCC deficiency, 3 β-hydroxysteroid
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Al-Jurayyan et al.: The spectrum of 46XY disorders of sex development 3 Table 1: Clinical spectrum of 56 patients with 46XY disorders of sex development at King Khalid University Hospital (1989–2010). Diagnosis
No.
%
Androgen insensitivity – Complete – Partial
16 5 11 9
28.6% 16.1%
Congenital malformation (dysmorphism) – Local anorectal – Generalized Extreme prematurity Congenital adrenal hyperplasia (due to 3-β-hydroxysteroid dehydrogenase deficiency) Hypogonadotrophic hypogonadism Ovotesticular 46XY, DSD Hypospadius Persistence of Mullerian ducts syndrome 46XY DSD due to abnormalities of gonadal development – Swyer syndrome – Denys-Drash syndrome
14
25%
Six newborns with microphallus Four newborns with ambiguous genitalia Four children: presence of inguinal masses, which later identified as testes during surgery One adolescent girl: first seen in the teenage years for evaluation of primary amenorrhea One adolescent boy: with PAIS had gynecomastia and impaired phallic growth Six newborns: with ambiguous genitalia; have either relatives with DSDs, neonatal deaths, amenorrhea, or infertility and consanguinity Three children: with micropenis and varying degrees of hypospadia – Phallus 1–2 cm Dysmorphism including microphallus and/or anal abnormalities
4 10 1 5
1.8% 8.9%
Microphallus Ambiguous genitalia
4
7.1%
Delayed puberty – micropenis
1 3 1
1.8% 5.4% 1.8%
Microphallus with chordee, proximal hypospadias and bifid scrotal folds Varying degrees Ambiguous genitalia
2
3.6%
Externally female newborns with
1 1
5-α-reductase deficiency
Clinical remarks
– Streaky gonads and UTI (dysgenesis) – (Swyer syndrome) –Nephropathy associated with Wilm’s tumour – (Denys-Drash syndrome)
DSD, disorders of sex development; PAIS, partial androgen insensitivity syndrome; UTI, urinary tract infection.
dehydrogenase type II deficiency, 17-α-hydroxylase and 17,20 lyase deficiency, isolated 17,20 lyase deficiency, P450 oxidoreductase “POR” gene defect, 17 β-hydroxysteroid dehydrogenase III deficiency result in androgen synthesis defect. Severely affected infants for POR gene of both sexes have ambiguous genitalia. Disorders of antiMüllerian hormone (AMH) and AMH receptors result in persistent Mullerian duct syndrome (PMDS) which is inherited in a sex-limited autosomal recessive manner and caused by a mutation in the AMH or AMH receptor genes. 5-α-Reductase type 2 deficiency and complete or partial forms of androgen insensitivity syndrome (CAIS, PAIS) result in disorders of androgen activities (13–25). Finally, one should look for the presence of other anomalies of morphogenesis which usually indicates a non-endocrine cause for the appearance of genitalia (26, 27). A variety of etiology is clearly evident in our series (Table 1). In general, consanguinity is more frequent and severity of ambiguous genitalia (AG) is higher in 5-α-reductase type 2 deficiency patients. T/DHT ratio may help the investigation of 46XY patients with AG and normal T synthesis. In Saudi Arabia, the rate of consanguineous mating is high (28, 29). This may explain the high rate
of 5-α-reductase deficiency, which is autosomal recessive, among our population, but not for the AIS which is X-linked inherited. Furthermore, involvement of other siblings is another factor (e.g., three families with 5-α-reductase deficiency in our cohort). Our finding is similar to the finding of Abdullah et al. from Sudan who found that AIS was the most common cause of 46XY DSD in their study population (3). Moreover, similar to our observation, they found that there were delays in case referrals due to lack of awareness and sociocultural reasons (3). Other studies in the Middle East, Italy, and Turkey had explored 46XY DSD from different prespectives and reported more or less similar etiology with little variations from our spectrum (7, 30–33). The expression of the 5-α-reductase iso-enzyme 2 was shown by some molecular studies, as well as some common mutations such as in steroidogenic factor 1 (SF1, NR5A1) and G34R in Egyption patients with 46XY DSD (30, 31). A first report of an Italian population emphasized the importance of differential diagnoses in patients with undervirilization. The lack of precise genotype-phenotype correlation in some of the mutations highlighted the necessity of understanding the interactions of genetic and environmental factors and
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4 Al-Jurayyan et al.: The spectrum of 46XY disorders of sex development the biochemical aspects of steroid 5-α-reductase action (32). In the Turkish experience, the less severe the phenotype they found in their population, the less likely is the chance of demonstrating a mutation. Moreover, a significant number of children with presumptive diagnosis of AIS had mutations in SRD5A2 gene in their cohort and are clinically and biochemically indistinguishable from AIS (33). Despite a wide range of variation in the phenotypes due to different mutations in androgenic receptors in AIS, however, the distinct phenotypic variation of AIS observed in patients reported in different studies including ours is possibly explained by differences in the availability of 5-α-dihydrotestosterone during embryonic sex differentiation (34). The management of 46XY DSD patients requires an appropriately trained multidisciplinary team (1–6, 8–13). Early diagnosis is important for a good outcome of the patients and should start with a detailed history including family history, any similar disease, neonatal deaths, and any maternal drug ingestion during pregnancy. A careful examination of the newborn’s genitalia and anus, as well as any dysmorphology at birth should be conducted. Psychological evaluation is extremely important during the periods before and after genioplasty. A simple and honest detailed and comprehensive explanation about what to expect to parents, and patient when appropriate, is of a paramount importance. The determination of the gender must take into account the etiological diagnosis, penile size, and function and fertility (35, 36). Fertility potential should be considered by the multidisciplinary team when addressing gender assignment, when discussing surgical management options, and during the process of sharing information with patients and their families about prospective long-term outcomes (37). Last but not least, religious opinion should not be ignored (1, 3). The risk for germ cell tumors is increased in such patients and should not be overlooked (4). Currently, in vitro fertilization techniques has enabled some 46XY DSD patients to produce offsprings (38).
Conclusion A wide spectrum of causes were noted. Androgen insensitivity syndrome and 5-α-reductase deficiency were among the commonest in our patients. There is no precise frequency estimation of AIS worldwide. Having high rate of consanguineous mating in Saudi Arabia, this may explain why 5-α-reductase deficiency was common. Also, local ano-rectal anomalies were not that rare.
Ethical considerations: Ethical approval for this study was obtained from the Institutional Review Board at King Khalid University Hospital. Acknowledgments: The authors would like to thank Ms. Loida M. Sese for her secretarial assistance and extend their thanks and appreciation to the College of Medicine Research Centre, Deanship of Scientific Research, King Saud University, Riyadh, for funding this work.
References 1. Al Jurayyan NA. Disorders of sex development: diagnostic approaches and management options. An islamic perspective. Malaysian J Med Sci 2011;18:4–12. 2. Al-Jurayyan NA. Ambiguous genitalia: two decades of experience. Ann Saudi Med 2011;31:284–88. 3. Abdullah MA, Saeed V, Abass A, Lubna K, Weam A, et al. Disorders of sex development among Sudanese children; 5-year experience of pediatric endocrinology clinic. J Pediatr Endocrinol Metab 2012;25:1065–72. 4. Cools M, Looijenga HJ, Wolffenbuttel KP, Drop SL. Disorders of sex development: update on the gentic background, terminology and risk for the development of germ cell tumours? World J Pedaitr 2009;5:93–102. 5. Ocal G. Current concept in disorders of sexual development. J CLin Res Pedaitr Endocrinol 2011;3:105–14. 6. Hiort O. Neonatal endocrinology of abnormal male sexual differentiation: molecular aspects. Horm Res 2000;53(Suppl 1): 38–41. 7. Tantawy S, Mazen I, Soliman H, Anwar G, Atef A, et al. Analysis of the gene coding for steroidogenic factor 1 (SF1, NR5A1) in a cohort of 50 Egyptian patients with 46,XY disorders of sex development. Eur J Endocrinol 2014;170:759–67. 8. Hughes IA. Disorders of sex development: a new definition and classification. Best Pract Res Clin Endocrinol Metab 2008;22:119–34. 9. Warne GL, Kanumakala S. Molecular endocrinology of sex differentiation. Semin Reprod Med 2002;20:169–80. 10. Gonul O. Current concepts in disorder of sexual development. J Clin Res Pediatr Endocrinol 2011;3:22–31. 11. Ahmed SF, Hughes A. The genetics of male under masculinization. J Clin Endocrinol 2002;56:1–10. 12. Mendonca BB, Domenice S, Amhold JP, Costa EM. 46 XY disorder of sex development. Clin Endocrinol (Oxf). 2009;70:173–87. 13. Scott RR, Miller WL. Genetic and clinical features of P450 oxidoreductase deficiency. Horm Res 2008;69:269–75. 14. Moshiri M, Chapman T, Fechner PY, Dubinsky TJ, Shnorhavorian M, et al. Evaluation and management of disorders of sex development: multidisciplinary approach to a complex diagnosis. Radiographic 2012;32:1500–618. 15. Palmer BW, Wisniewski AB, Schaeffer TL, Mallappa A, Tryggestad JB, et al. A model of delivering multi-disciplinary care to people with 46, XY DSD. J Pediatr Uro 2012;8:7–16.
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Al-Jurayyan et al.: The spectrum of 46XY disorders of sex development 5 16. Wisniewski AB. Gender development in 46, XY DSD: influence of chromosomes, hormones, and intrauterine with parents and health care professionals Scientifica (Cairo) 2012;2012:834967. 17. Wisniewski AB, Chesnausek SD, Kropp BP. Disorder of sex development: a practical guide for parents and physicians. Baltimore, MD: The John Hopkins University Press, 2012. 18. Imperato-McGinley J, Gautier T, Pichadro M. Diagnosis of 5-α-reductase deficiency in infancy. J Clin Endocrinol Metab 1986;63:1313–8. 19. Cheon CK. Practical approach to steroid 5-α-reductase type 2 deficiency. Eur J Pediatr 2011;170:1–8. 20. Hughes IA, Davies VD, Bunch TI, Paslerski V, Mastrayannopoulou K, et al. Androgen insensitivity syndrome. Lancet 2012;12:60071–3. 21. Bashamboo H, Lodig S, Wieacker P, Achermann JC, Mc Elreavey K. New technologies for the identification of novel genetic markers of disorders of sex development DSD. Sex Dev 2010;4:213–24. 22. Schweiket H. The androgen resistance syndrome. Clinical and biochemical aspects. Eur J Pedaitr 1993;(Suppl 2):550–7. 23. Griffin JE, Wilson JD. The androgen resistance syndromes: α-reductase deficiency, testicular feminization, and related syndromes. In: Scriver CR, Beaudet AL, Sly WS, Valle D, editors. The metabolic basis of inherited diseases 6th ed. New York: Mc Graw-Hill, 1989:1919–44. 24. Maimoun L, Philibert P, Cammas B, Audran F, Bouchard P, et al. Phenotypical, biological and molecular heterogeneity of 5-α-reductase deficiency: an extensive international experience of 55 patients. J Clin Endocrinol Metab 2011;96:296–307. 25. Oakes MB, Eyrazzadeh AD, Quint E, Smith YR. Complete androgen insensitivity syndrome, a review. J Pediatr Adolesc Gynecol 2008;21:305–10. 26. Dincsoy MY, Salih MA, Al-Jurayyan NA, Al Saadi M, Petal PJ. Multiple congenital malformation in two sibs reminiscent of hydrolethalus and pseudotrisomy 13 syndromes: new syndrome. American J Med Genet 1995;56:317–21. 27. Pavone L, Le Pira A, Caruso M, Pavone P, Palumbo O, et al. A new cause of ambiguous genitalia multiple malfunction syndrome related to unbalanced translocation 46, XYt (7,16). Internet J Pediatr Neonatol 2010;12. DOI:10.5580/C5F.
28. Saedi-Wong S, Al Frayh AR, Wong HY. Socio-economicepidemiology of consanguineous matings in Saudi Arabian population. J Asian Afr Stu 1989;24:7–52. 29. El Mouzan MI, Al Salloum A, Al Herbish AS, Qurachi MM, Al Omar AA. Regional variations in the prevalence of consanguinity in Saudi Arabia. Saudi Med J 2007;28:1881–4. 30. Ismail SI, Mazen IA. A study of gender outcome of Egyptian patients with 46,XY disorder of sex development. Sex Dev 2010;4:285–91. 31. Gad YZ, Khairt R, Mazen I, Osman HG. Detection of the G34R mutation in the 5 alpha reductase 2 gene by allele specific PCR and its linkage to the 89L allele among Egyptian cases. Sex Dev 2007;1:293–6. 32. Nicoletti A, Baldazzi L, Balsamo A, Barp L, Pirazzoli P, et al. SRD5A2 gene analysis in an Italian population of under-masculinized 46,XY subjects. Clin Endocrinol (Oxf) 2005;63:375–80. 33. Akcay T, Fernandez-Cancio M, Turan S, Güran T, Audi L, et al. AR and SRD5A2 gene mutations in a series of 51 Turkish 46,XY DSD children with a clinical diagnosis of androgen insensitivity. Andrology 2014;2:572–8. 34. Boehmer AL, Brinkmann AO, Nijman RM, Verleun-Mooijman MC, de Ruiter P, et al. Phenotypic variation in a family with partial androgen insensitivity syndrome explained by differences in 5alpha dihydrotestosterone availability. J Clin Endocrinol Metab 2001;86:1240–6. 35. Vidal I, Gorduza DB, Haraux E, Gay CL, Chatelain P, et al. Surgical options in disorders of sex development (DSD) with ambiguous genitalia. Best Pract Res Clin Endocrinol Metab 2010;24:311–24. 36. Nihoul-Fekete C, Thibaud E, Lortat-Jacob S, Josso N. Long-term surgical results and patients satisfaction with male pseudohermaphroditism or true hermaphroditism: a cohort of 63 patients. J Urol 2006;175:1878–84. 37. Guercio G, Rey RA. Fertility issues in the management of patients with disorders of sex development. Endocr Dev 2014;27:87–98. 38. Katz MD, Kligman I, Cai LQ, Zhu YS, Fratianni CM, et al. Paternity by intrauterine insemination with sperm from a man with 5 α-reductase-2-deficiency. N Engl J Med 1997;336:994–7.
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Nasir A.M. Al-Jurayyan, Sharifah D.A. Al Issa, Abdulrahman M.H. Al Nemri, Hessah M.N. Al Otaibi and Amir M.I. Babiker*
The spectrum of 46XY disorders of sex development in a University centre in Saudi Arabia Abstract Background: The term disorders of sex development (DSD) includes congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical. The spectrum of the 46XY (DSD) is so broad. In this study, we reviewed the clinical spectrum of a cohort of patients with 46XY DSD in a tertiary institute in the Middle East over two decades. Objective: To define the clinical spectrum of 46XY DSD in a major teaching hospital, Riyadh, Saudi Arabia. Materials and methods: This is a retrospective, case series hospital-based study. The case notes, laboratory investigations, and imaging studies were reviewed for patients with 46XY DSD over a 20 years period (1989–2010) at King Khalid University Hospital, Riyadh, Saudi Arabia. Molecular genetics were not available in all patients. Results: During the period under review; a total of 56 patients were seen with 46XY DSD due to variable etiologies. Androgen insensitivity syndromes (AIS) and 5-α-reductase deficiency were among the commonest (44.6%), with multiple siblings involvement within the family. Of these, 16 patients were showing variable degrees of insensitivity ranging between complete (n = 5, 31.2%) and partial (n = 11, 68.8%) insensitivity, whereas in nine patients the diagnosis of 5-α-reductase deficiency was entertained based on hormonal studies. Of interest to see was a high number of patients (n = 14, 25%) either with a localized congenital anomalies such as the cloacal anomalies or generalized congenital malformations following the pattern of certain syndromes. *Corresponding author: Dr. Amir M.I. Babiker, FRCPCH (UK), Department of Pediatrics (39), College of Medicine and KKUH, P.O. Box 2925, Riyadh 11461, Saudi Arabia, Phone: +966-537806560, Fax: +966-114679463, E-mail: [email protected]; [email protected] Nasir A.M. Al-Jurayyan, Sharifah D.A. Al Issa, Abdulrahman M.H. Al Nemri and Hessah M.N. Al Otaibi: Department of Pediatrics, College of Medicine and King Khalid University Hospital (KKUH), King Saud University, Riyadh, Saudi Arabia
Conclusion: A wide spectrum of causes were noted. Androgen insensitivity syndrome was the commonest. In Saudi Arabia, where consanguineous mating is high, 5-α-reductase is also a common cause of 46XY DSD. Keywords: ambiguous genitalia; DSD; Saudi Arabia; spectrum; 46XY. DOI 10.1515/jpem-2014-0503 Received December 5, 2014; accepted April 2, 2015
Introduction Normal male sexual differentiation is a complex mechanism, depending on genetic and hormonal control. The bipotential gonad arises at the genital ridge under the control of autosomal genes which are also involved in the formation of other organs. Progression toward testicular differentiation is mediated through both autosomal and some specific genes, leading to alignment of Sertoli cells and Leyding cells. Within the latter, androgen formation is induced by human chorionic gonadotrophin (hCG) and luteinizing hormones (LH). The influence of testosterone and dihydrotestosterone leads to differentiation of epidydimis, vas deferens, prostate, and external genitalia. Androgens mediate their action through the androgen receptor, a nuclear transcription factor controlling the regulation of so far the unknown target genes. Genetic variations within the pathway interrupt normal male development and will lead to malformation of the external and or internal genitalia (1–6). Steroidogenic factor 1 (SF1, NR5A1) is currently a key transcriptional regulator of genes involved in the hypothalamic-pituitary-gonadal axis and SF1 mutations were found to be a frequent cause of 46XY disorders of sex development (DSD) (7). Yet, the investigation for SF1 mutation was not performed in our patients in this study. The spectrum of 46XY DSD is so broad and characterized by incomplete intrauterine masculinization, and the
Brought to you by | HEC Bibliotheque Maryriam ET J. Authenticated Download Date | 8/14/15 8:12 AM
2 Al-Jurayyan et al.: The spectrum of 46XY disorders of sex development presence or absence of Mullerian structures. Complete absence of virilization resulting in a normal female external genitalia can result from gonadotrophin deficiency, testosterone biosynthesis, or action defects or abnormalities of gonadal development (8). These patients generally seek medical attention at pubertal age, due to the absence of breast development and/or primary amenorrhea (8–12). The psychological and social implications of gender assignment require a multi-disciplinary approach and an experienced team which includes a geneticist, neonatologist, endocrinologist, psychiatrists, pediatric surgeon, or pediatric urologist and social workers (13, 14). This study aims to highlight and express the importance of considering the various causes in the differential diagnosis. It is one of the first reports on a longitudinal data from Saudi Arabia highlighting the spectrum of such a rare, yet socially and medically important condition, which requires careful medical attention.
Materials and methods The study population consisted all patients presented to the pediatric endocrine and pediatric clinics, King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia over a 20-year period (1989–2010). King Khalid University Hospital is one of the main referral hospitals in Riyadh City and considered as the main teaching hospital for King Saud University. The hospital provides primary, secondary, and tertiary health care services for the local population and also receives patients referral from all over the country. Reviewing the clinical notes of patients with 46XY DSD in the study population, in retrospect, ambiguous genitalia was considered when there was difficulty in determining the sex of patient on initial examination or when the external genitalia showed significant structural deviation from normal in an apparent male or female. The appropriate diagnostic (radiological and serological) evaluation were performed for all patients in the study (2). Routine tests included karyotype, follicular stimulating hormone (FSH), LH, testosterone (T), estradiol, adrenal androgens, serum electrolytes, urinalysis, and abdominal and pelvic ultrasounds. Additional tests, as clinically indicated, included 17 hydroxyprogestrone, dihydrotestosterone (DHT), renal fuction tests, and renal ultrasound when there was suspected associated renal impairment. Laparoscopy and gonadal biopsy were performed when appropriate; however, none of them showed evidence of gonadoblastoma. The following criteria were used to support the diagnosis of 5-α-reductase: karyotype 46XY, T:DHT ratio of > 10 as baseline and > 20 post hCG injections, other hormonal tests that help in ruling out other differential diagnoses and absence of female organs, not as in androgen insensitivity syndrome (AIS), in pelvic ultrasound scan. Both T, which was tested locally, and DHT, which was tested in different labrotaries in Europe and America, were assessed by radioimmunoassay. T was evaluated at basal levels in all patients, and in all prepubertal patients following an hCG stimulation test (1500 IU of hCG given by intramuscular injections) for 3 consecutive days
on an outpatient basis. Venous samples were taken before the test and approximately 24 h after the 3rd hCG injection. All patients were managed by an experienced multidisciplinary team.
Results During the period under review; a total of 56 patients were seen with 46XY DSD due to variable etiologies. AIS and 5-α-reductase deficiency were among the commonest (44.6%), with multiple siblings involvement within the family (three families of 5-α-reductase deficiency in our series). Of these, 16 patients were showing variable degrees of insensitivity ranging between complete (n = 5, 31.2%) and partial (n = 11, 68.8%) insensitivity, while in nine patients the diagnosis of 5-α-reductase deficiency was entertained based on hormonal studies. Molecular genetics were not available in all patients in this retrospective study. Of interest to see was a high number of patients (n = 14, 25%) either with a localized congenital anomalies, such as the cloacal anomalies or generalized congenital malformations following the pattern of certain syndromes. Laparoscopy and gonadal biopsies were performed when appropriate and it did not reveal gonadoblastoma in any of our patients.
Discussion The spectrum of causes of 46XY DSD is so broad (Table 1). To elucidate the cause can be time consuming and sometimes difficult. In addition to radiological studies, specific diagnostic tests including genetic and hormonal studies and therapeutic trials should be obtained (8–12). Previously called male pseudohermaphrodite, 46XY DSD, can result either from disorders of testicular development or in androgen synthesis or action. Male gonads are palpable in the majority of 46XY DSD patients. Abnormalities in the expression of genes involved in the cascade of testis determination can cause anomalies of gonads development (complete or partial forms of gonadal dysgenesis with or without syndromic phenotype, ovotesticular DSD, testicular regression syndrome). Mutation in certain genes (WT1) results in Denys-Drash syndrome or Fraiser syndrome. Complete gonadal dysgenesis (Swyer syndrome) with a female phenotype with a full development of Mullerian structures, and streak of gonads. Leydig cell aplasia or hypoplasia, due to abnormalities in hCG/ LH receptor and testosterone biosynthesis defect (STAR) deficiency, P450 SCC deficiency, 3 β-hydroxysteroid
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Al-Jurayyan et al.: The spectrum of 46XY disorders of sex development 3 Table 1: Clinical spectrum of 56 patients with 46XY disorders of sex development at King Khalid University Hospital (1989–2010). Diagnosis
No.
%
Androgen insensitivity – Complete – Partial
16 5 11 9
28.6% 16.1%
Congenital malformation (dysmorphism) – Local anorectal – Generalized Extreme prematurity Congenital adrenal hyperplasia (due to 3-β-hydroxysteroid dehydrogenase deficiency) Hypogonadotrophic hypogonadism Ovotesticular 46XY, DSD Hypospadius Persistence of Mullerian ducts syndrome 46XY DSD due to abnormalities of gonadal development – Swyer syndrome – Denys-Drash syndrome
14
25%
Six newborns with microphallus Four newborns with ambiguous genitalia Four children: presence of inguinal masses, which later identified as testes during surgery One adolescent girl: first seen in the teenage years for evaluation of primary amenorrhea One adolescent boy: with PAIS had gynecomastia and impaired phallic growth Six newborns: with ambiguous genitalia; have either relatives with DSDs, neonatal deaths, amenorrhea, or infertility and consanguinity Three children: with micropenis and varying degrees of hypospadia – Phallus 1–2 cm Dysmorphism including microphallus and/or anal abnormalities
4 10 1 5
1.8% 8.9%
Microphallus Ambiguous genitalia
4
7.1%
Delayed puberty – micropenis
1 3 1
1.8% 5.4% 1.8%
Microphallus with chordee, proximal hypospadias and bifid scrotal folds Varying degrees Ambiguous genitalia
2
3.6%
Externally female newborns with
1 1
5-α-reductase deficiency
Clinical remarks
– Streaky gonads and UTI (dysgenesis) – (Swyer syndrome) –Nephropathy associated with Wilm’s tumour – (Denys-Drash syndrome)
DSD, disorders of sex development; PAIS, partial androgen insensitivity syndrome; UTI, urinary tract infection.
dehydrogenase type II deficiency, 17-α-hydroxylase and 17,20 lyase deficiency, isolated 17,20 lyase deficiency, P450 oxidoreductase “POR” gene defect, 17 β-hydroxysteroid dehydrogenase III deficiency result in androgen synthesis defect. Severely affected infants for POR gene of both sexes have ambiguous genitalia. Disorders of antiMüllerian hormone (AMH) and AMH receptors result in persistent Mullerian duct syndrome (PMDS) which is inherited in a sex-limited autosomal recessive manner and caused by a mutation in the AMH or AMH receptor genes. 5-α-Reductase type 2 deficiency and complete or partial forms of androgen insensitivity syndrome (CAIS, PAIS) result in disorders of androgen activities (13–25). Finally, one should look for the presence of other anomalies of morphogenesis which usually indicates a non-endocrine cause for the appearance of genitalia (26, 27). A variety of etiology is clearly evident in our series (Table 1). In general, consanguinity is more frequent and severity of ambiguous genitalia (AG) is higher in 5-α-reductase type 2 deficiency patients. T/DHT ratio may help the investigation of 46XY patients with AG and normal T synthesis. In Saudi Arabia, the rate of consanguineous mating is high (28, 29). This may explain the high rate
of 5-α-reductase deficiency, which is autosomal recessive, among our population, but not for the AIS which is X-linked inherited. Furthermore, involvement of other siblings is another factor (e.g., three families with 5-α-reductase deficiency in our cohort). Our finding is similar to the finding of Abdullah et al. from Sudan who found that AIS was the most common cause of 46XY DSD in their study population (3). Moreover, similar to our observation, they found that there were delays in case referrals due to lack of awareness and sociocultural reasons (3). Other studies in the Middle East, Italy, and Turkey had explored 46XY DSD from different prespectives and reported more or less similar etiology with little variations from our spectrum (7, 30–33). The expression of the 5-α-reductase iso-enzyme 2 was shown by some molecular studies, as well as some common mutations such as in steroidogenic factor 1 (SF1, NR5A1) and G34R in Egyption patients with 46XY DSD (30, 31). A first report of an Italian population emphasized the importance of differential diagnoses in patients with undervirilization. The lack of precise genotype-phenotype correlation in some of the mutations highlighted the necessity of understanding the interactions of genetic and environmental factors and
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4 Al-Jurayyan et al.: The spectrum of 46XY disorders of sex development the biochemical aspects of steroid 5-α-reductase action (32). In the Turkish experience, the less severe the phenotype they found in their population, the less likely is the chance of demonstrating a mutation. Moreover, a significant number of children with presumptive diagnosis of AIS had mutations in SRD5A2 gene in their cohort and are clinically and biochemically indistinguishable from AIS (33). Despite a wide range of variation in the phenotypes due to different mutations in androgenic receptors in AIS, however, the distinct phenotypic variation of AIS observed in patients reported in different studies including ours is possibly explained by differences in the availability of 5-α-dihydrotestosterone during embryonic sex differentiation (34). The management of 46XY DSD patients requires an appropriately trained multidisciplinary team (1–6, 8–13). Early diagnosis is important for a good outcome of the patients and should start with a detailed history including family history, any similar disease, neonatal deaths, and any maternal drug ingestion during pregnancy. A careful examination of the newborn’s genitalia and anus, as well as any dysmorphology at birth should be conducted. Psychological evaluation is extremely important during the periods before and after genioplasty. A simple and honest detailed and comprehensive explanation about what to expect to parents, and patient when appropriate, is of a paramount importance. The determination of the gender must take into account the etiological diagnosis, penile size, and function and fertility (35, 36). Fertility potential should be considered by the multidisciplinary team when addressing gender assignment, when discussing surgical management options, and during the process of sharing information with patients and their families about prospective long-term outcomes (37). Last but not least, religious opinion should not be ignored (1, 3). The risk for germ cell tumors is increased in such patients and should not be overlooked (4). Currently, in vitro fertilization techniques has enabled some 46XY DSD patients to produce offsprings (38).
Conclusion A wide spectrum of causes were noted. Androgen insensitivity syndrome and 5-α-reductase deficiency were among the commonest in our patients. There is no precise frequency estimation of AIS worldwide. Having high rate of consanguineous mating in Saudi Arabia, this may explain why 5-α-reductase deficiency was common. Also, local ano-rectal anomalies were not that rare.
Ethical considerations: Ethical approval for this study was obtained from the Institutional Review Board at King Khalid University Hospital. Acknowledgments: The authors would like to thank Ms. Loida M. Sese for her secretarial assistance and extend their thanks and appreciation to the College of Medicine Research Centre, Deanship of Scientific Research, King Saud University, Riyadh, for funding this work.
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