Deborah P. Merke, MD; Stefan R. Bornstein, MD; Nilo A. Avila, MD; George P. Chrousos, MD
Merke DP, Bornstein SR, Avila NA, Chrousos GP. Future Directions in the Study and Management of Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency. Ann Intern Med. 2002;136:320-334. doi: 10.7326/0003-4819-136-4-200202190-00012
Download citation file:
Published: Ann Intern Med. 2002;136(4):320-334.
In a person with normal adrenal function ( ), the adrenal gland produces both cortisol and androgen. The hypothalamic-pituitary-adrenal axis is controlled by negative feedback. In the untreated patient with CAH ( ), a block in cortisol biosynthesis leads to a buildup of cortisol precursors and lack of negative feedback. Corticotropin ( ) is oversecreted, and adrenal hyperplasia occurs. The combination of accumulated cortisol precursors and increased ACTH results in massive androgen production. In the treated patient with CAH ( ), exogenous hydrocortisone replacement reduces androgen production. Supraphysiologic doses of hydrocortisone are often necessary to adequately suppress androgen production. CRH = corticotropin-releasing hormone.
The location and nature of each microconversion and the expected clinical phenotype (salt-losing [ ], non-salt-losing [ ], and nonclassic congenital adrenal hyperplasia [ ]) are shown. The 10 exons and 9 introns of are drawn to scale. Arg = arginine; Asn = asparagine; Asp = aspartate; Glu = glutamate; Ile = isoleucine; Leu = leucine; Lys = lysine; Met = methionine; Pro = proline; Trp = tryptophan; Val = valine.
Steroidogenic acute regulatory protein ( ) expression is increased in the adrenal glands of mice with 21-hydroxylase deficiency, as compared with wild-type animals. Quantitative steroidogenic acute regulatory protein was determined by TaqMan PCR Core Reagents Kit (Applied Biosystems, Foster City, California) ( = 4 adrenal glands; < 0.05). Amounts of RNA were calculated with relative standard curves for both steroidogenic acute regulatory protein and 18S. The amount of messenger RNA was corrected by division by the amount of 18S RNA in each sample. Electroµgraph showing catecholamine-storing secretory vesicles in chromaffin cells of control animals (size range, 50 to 450 nm). Electroµgraph of chro-maffin cells. Secretory granules are markedly reduced in chromaffin cells of 21-hydroxylase-deficient mice. The remaining granules are predominantly electron-dense, norepinephrine-containing vesicles, lying in large lucent vacuoles ( ). For parts B and C, stain is uranyl acetate and lead citrate, and magnification is × 15 000. MIT = mitochondria.
The treatment outcome in classic congenital adrenal hyperplasia is often suboptimal because of incomplete suppression of hyperandrogenism ( ), treatment-induced hypercortisolism ( ), or both. At 16 years of age, a female patient with salt-losing 21-hydroxylase deficiency due to undertreatment with glucocorticoid and elevated androgen levels had hirsutism, acne, amenorrhea, and hyperpigmentation ( ). Increased glucocorticoid treatment resulted in weight gain with cushingoid features and short stature in a male patient with classic 21-hydroxylase deficiency ( ).
Fludrocortisone is given in the usual manner. The hydrocortisone dose is reduced to physiologic levels, resulting in elevated androgen production. An antiandrogen agent is administered to block the effect of the elevated androgen levels, and an inhibitor of androgen-to-estrogen conversion is given to block conversion of the increased amount of androgen to estrogen.
Elevations in adrenocorticotropic hormone, increases in neural-adrenomedullary input, and presence of insulin-mediated metabolic input may lead to adrenal hyperandrogenism and premature adrenarche. In turn, adrenal hyperandrogenism, insulin resistance, or both may lead to full-blown polycystic ovary syndrome in a woman with an inherent ovarian vulnerability. ACTH = adrenocorticotropic hormone; CRH = corticotropin-releasing hormone; E = epinephrine; NE = norepinephrine; NPY = neuropeptide Y.
Testicular adrenal rest tissue masses often surround the mediastinum testes ( ) ( ), and are bilateral, intratesticular, and hypoechoic ( ). Testicular adrenal rest tissue masses are seen equally as well on ultrasonography and magnetic resonance imaging. Most of these masses are hypointense on T2-weighted images ( ) and isointense on T1-weighted images, with diffuse enhancement post-contrast ( ). Large testicular adrenal rest tissue ( ) typically shrinks or disappears ( ) with higher-dose glucocorticoid therapy.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Copyright © 2017 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only