Accuracy of Urinary Etiocholanolone/Androsterone Ratio as Alternative to Serum Testosterone/Dihydrotestosterone Ratio for Diagnosis of 5 Alpha-reductase Type 2 Deficiency Patients and Carriers in Indonesia

Background: The 5 Alpha-reductase type 2 deficiency (5ARD2) is an inherited condition, which clinically presents as variable degrees of under virilization in affected 46,XY individuals. In the diagnostic pathway of 5ARD2, the testosterone/dihydrotestosterone (T/DHT) ratio is broadly employed before molecular analysis of the SRD5A2 gene. However, due to cost-benefit considerations, the DHT test in our country is routinely lacking in clinical settings; therefore, we considered applying the urinary etiocholanolone/androsterone (Et/An) ratio as an alternative test. Objectives: We aimed to determine the diagnostic value of the urinary Et/An ratio versus the T/DHT ratio in diagnosing 5ARD2 patients and carriers. Methods: Sixty-six suspected 5ARD2 46,XY disorders of sex development (DSD) individuals and 95 family members were recruited in the study. Their physical manifestations, T/DHT and urinary Et/An ratios, and SRD5A2 genes were analyzed. Using molecular analysis of the SRD5A2 gene as the gold standard, we compared the accuracy of both ratios in diagnosing 5ARD2 patients and carriers with receiver operating characteristic (ROC) curve analysis. Results: Thirty-seven patients were confirmed molecularly to have 5ARD2, and the rest (n = 29) were assessed as normal controls, while in the carrier group, 53 were molecularly confirmed as carriers and 42 as controls. The AUCs (areas under the curve) of the T/DHT and urinary Et/An ratios were 57.7% (95% CI 43.0 - 72.4%, P > 0.05) and 79.7% (95% CI 69.0 - 90.4%, P < 0.001), respectively, in diagnosing 5ARD2 patients and 54.1% (95% CI 42.4 - 65.8%, P > 0.05) and 75.1% (95% CI 65.1 - 85.1%, P < 0.001), respectively, in diagnosing carriers. The cutoff value of the urinary Et/An ratio was set at ≥ 0.95 for detecting 5ARD2 patients and ≥ 0.99 for detecting carriers. Conclusions: The testosterone/DHT ratio was inaccurate in diagnosing 5ARD2 patients. When molecular analysis for the SRD5A2 gene is lacking, the urinary Et/An ratio may be a useful test to diagnose 5ARD2 patients and carriers.

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Characterising SRD5A2 Gene Variants in 37 Indonesian Patients with 5-Alpha-Reductase Type 2 Deficiency

International Journal of Endocrinology ◽

10.1155/2019/7676341 ◽

2019 ◽

Vol 2019 ◽

pp. 1-10 ◽

Cited By ~ 1

Author(s):

Nanis S. Marzuki ◽

Firman P. Idris ◽

Hannie D. Kartapradja ◽

Alida R. Harahap ◽

Jose R. L. Batubara

Keyword(s):

Autosomal Recessive ◽

Disorders Of Sex Development ◽

External Genitalia ◽

Compound Heterozygous ◽

Phenotypic Characteristics ◽

Sex Development ◽

Srd5a2 Gene ◽

Diagnostic Approaches ◽

Autosomal Recessive Condition

The 5-alpha-reductase type 2 deficiency (5ARD2) is an autosomal recessive condition associated with impairment in the conversion of testosterone to dihydrotestosterone. This condition leads to undervirilisation in 46,XY individuals. To date, there have been more than 100 variations identified in the gene responsible for 5ARD2 development (steroid 5-alpha-reductase 2, SRD5A2). However, few studies have examined the molecular characterisation of Indonesian 5ARD2 cases. In the current study, we analysed 37 subjects diagnosed with 46,XY DSD (disorders of sex development) with confirmed variations in the SRD5A2 gene. We examined results from testosterone/dihydrotestosterone (T/DHT) and urinary etiocholanolone/androsterone (Et/An) ratios, as well as from molecular and clinical analyses. Twelve variants in the SRD5A2 gene were identified, and 6 of which were novel, namely, c.34–38delGinsCCAGC, p.Arg50His, p.Tyr136∗, p.Gly191Arg, p.Phe194Ile, and p.Ile253Val variants. Moreover, we determined that 20 individuals contained harmful mutations, while the remaining 17 variants were benign. Those containing harmful mutations exhibited more severe phenotypes with median external genitalia masculinisation scores (EMS) of 3 (1.5–9) and were more likely to be diagnosed at a later age, reared as female, and virilised at pubertal age. In addition, the respective sensitivities for detecting severe 5ARD2 cases using T/DHT (cutoff: 10) and urinary Et/An ratios (cutoff: 0.95) were 85% and 90%, whereas mild cases were only identified with 64.7% and 47.1% sensitivity, respectively. Although we were unable to identify clear correlations between genotypic and phenotypic characteristics in this study, we clearly showed that individuals who were homozygous or compound heterozygous for any of the harmful mutations were more likely to exhibit classic 5ARD2 phenotypes, lower EMS, female assignment at birth, and virilisation during puberty. These results serve to inform the development of improved clinical and molecular 5ARD2 diagnostic approaches, specifically in Indonesian patients.

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Molecular Analysis of the AR and SRD5A2 Genes in Patients with 46,XY Disorders of Sex Development

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2008-210609 ◽

2008 ◽

Vol 21 (6) ◽

pp. 545-554

Author(s):

Jin-Ho Choi ◽

Gu-Hwan Kim ◽

Eul-Ju Seo ◽

Kun-Suk Kim ◽

Sung Hoon Kim ◽

...

Keyword(s):

Molecular Analysis ◽

Dna Analysis ◽

Disorders Of Sex Development ◽

Plasma Renin ◽

Serum Testosterone ◽

Androgen Insensitivity Syndrome ◽

Reference Ranges ◽

Reductase Deficiency ◽

Sex Development ◽

Precise Diagnosis

Abstract The aim of this study was to assess the clinical and endocrinological features, and to analyze AR and SRD5A2 genes in patients with 46,XY disorders of sex development (DSD). This study included 20 patients from 19 families showing clinical features of 46,XY DSD. Molecular analysis was performed of the AR and SRD5A2 genes, as well as endocrinological evaluations, such as 17a-hydroxyprogesterone, plasma renin activity, aldosterone, adrenocorticotropic hormone and hCG stimulation test. Out of 20 patients with 46,XY DSD, only one (5%) displayed androgen insensitivity syndrome (AIS), and four (20%) were Sa-reductase deficient by mutation analysis. The patient with AIS revealed significant elevation of serum testosterone following hCG stimulation. The patient with Sa-reductase deficiency with a homozygous p.R246Q mutation had a low basal dihydrotestosterone level. The patient with p.Q6X/p.R246Q mutations showed a moderately elevated testosterone/ dihydrotestosterone ratio following hCG stimulation. Endocrinological tests are not reliable for the etiological diagnosis of AIS and Sa-reductase deficiency due to variable reference ranges of hormonal profiles according to the age and the severity of the enzyme defect. DNA analysis may be employed as a tool for the early and precise diagnosis of patients with 46,XY DSD, and genetic counseling can be used for families at risk.

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Genome analyses and androgen quantification for an infant with 5α-reductase type 2 deficiency

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2020-0678 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Kazuhisa Akiba ◽

Keiko Aso ◽

Yukihiro Hasegawa ◽

Maki Fukami

Keyword(s):

Disorders Of Sex Development ◽

Reference Value ◽

Ambiguous Genitalia ◽

Chinese Patients ◽

Sex Development ◽

Liquid Chromatography Tandem Mass ◽

Exon 1 ◽

Genome Analyses ◽

Immune Assays

Abstract Objectives 5α-reductase type 2 deficiency due to biallelic SRD5A2 variants is a common form of 46,XY disorders of sex development. Case presentation A Chinese neonate presented with ambiguous genitalia. He carried a homozygous likely_pathogenic SRD5A2 variant (c.650C>A, p.A217E). His apparently nonconsanguineous parents were heterozygotes for the variant. The variant has previously been identified in two Chinese patients. Our patient carried 14.2 Mb loss-of-heterogeneity regions distributed in the genome. The SRD5A2 variant in this family was invariably coupled with two polymorphisms in exon 1 and intron 1. In the patient, blood testosterone (T)/5α-dihydrotestosterone (5αDHT) ratios were elevated before and during mini puberty, and were higher when measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) than measured by conventional immune assays. Conclusions This study provides evidence for the founder effect of an SRD5A2 variant. Furthermore, our data indicate that there is a need to establish a new reference value for T/5αDHT ratios using LC-MS/MS.

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Isolated mild clitoral hypertrophy may reveal 46,XY disorders of sex development in infancy due to17βHSD-3defect confirmed by molecular analysis

Gynecological Endocrinology ◽

10.3109/09513590.2010.544134 ◽

2011 ◽

Vol 27 (11) ◽

pp. 890-894 ◽

Cited By ~ 5

Author(s):

Minu M. George ◽

Sunil Sinha ◽

Irene Mamkin ◽

Pascal Philibert ◽

Maria I. New ◽

...

Keyword(s):

Molecular Analysis ◽

Disorders Of Sex Development ◽

Sex Development

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46 XY DISORDER

The Professional Medical Journal ◽

10.29309/tpmj/2016.23.10.1723 ◽

2016 ◽

Vol 23 (10) ◽

pp. 1202-1208

Author(s):

Muhammad Naveed Najeeb ◽

Sadiq Hussain Malik ◽

Sheikh Khurram Salam Sehgal ◽

Ameer Ahmad Malik ◽

Saqib Mehmood

Keyword(s):

Physical Examination ◽

Study Design ◽

Gonadal Dysgenesis ◽

Disorders Of Sex Development ◽

Serum Testosterone ◽

Androgen Insensitivity Syndrome ◽

Base Line ◽

Reductase Deficiency ◽

Androgen Synthesis ◽

Sex Development

Objectives: The Disorders of Sex Development are classified as 46, XY DSD,46, XX DSD and Chromosomal DSD according to the chromosomal constitution of the affectedpersons. 46, XY DSD is further classified into Androgen Synthetic Defect, Androgen InsensitivitySyndrome Gonadal Dysgenesis, 5-Alpha Reductase Deficiency, Persistent Mullerian DuctSyndrome and Isolated Hypospadias according to the pathophysiology of the disease. Theaim of present study was to classify 46, XY patients into their subclasses on the basis of theirhormonal profile and physical examination. Study Design: Observational descriptive study.Setting: Biochemistry Department University of Health Sciences for Karyotyping and Geneticassessment, and its allied institution Biochemistry Department Quaid-e-Azam Medical CollegeBahawalpur for hormonal analysis, along with Pediatric Medicine Departments of Quaid-e-AzamMedical College / Bahawal Victoria Hospital Bahawalpur for collection of Sample and clinicalassessments. Period: June 2015 to December 2015. Study Design: Observational descriptivestudy. Material and Methods: 53 patients with 46, XY DSD were recruited. Complete clinicalhistory and data of each patient was recorded in the research proforma. Genitals examinedfor the phallus length and size, position of urinary meatus, palpation of gonads and shape ofthe labioscrotal folds. Ultrasonography examination of each patient was performed to look forundescended testes and for the presence of either male or female internal reproductive organs.Results: Base line levels of serum Testosterone Dihydrotestosterone Luteinizing hormone,Follicle stimulating hormone, 17-OH-Progesteron and Anti-mullerian hormones were measuredby ELISA technique. Testosterone and DHT were measured again after hCG stimulation. Onthe basis of physical examination, ultrasonographic findings and hormonal profile diagnosisof the types of 46, XY DSD was possible in 27 (51%) of patients. Androgen synthesis defect asa cause of 46, XY DSD was diagnosed in 7(13%) patients, Androgen insensitivity syndrome in6(11%) patients, 5-Alpha reductase deficiency in 3(6%) patients, Gonadal Dysgenesis in 3 (6%),Persistent Mullerian Duct Syndrome in 3(6%) and Isolated Hypospadias in 2 (4%) patients.There were 26 (49%) patients which remain undiagnosed with the algorithm of diagnosis usedin the present study.

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Diagnosis of 5α-Reductase 2 Deficiency: Is Measurement of Dihydrotestosterone Essential?

Clinical Chemistry ◽

10.1373/clinchem.2012.196501 ◽

2013 ◽

Vol 59 (5) ◽

pp. 798-806 ◽

Cited By ~ 23

Author(s):

Angel On Kei Chan ◽

Betty Wai Man But ◽

Ching Yin Lee ◽

Yuen Yu Lam ◽

Kwok Leung Ng ◽

...

Keyword(s):

Mutational Analysis ◽

Disorders Of Sex Development ◽

Laboratory Findings ◽

Direct Dna Sequencing ◽

Sex Development ◽

Srd5a2 Gene ◽

Review Period ◽

Steroid Profiling ◽

Steroid Metabolite ◽

Urinary Steroid

BACKGROUND 5α-Reductase 2 deficiency (5ARD) is a known cause of 46,XY disorders of sex development (DSD). Traditionally, the diagnosis relies on dihydrotestosterone (DHT) measurement, but the results are often equivocal, potentially leading to misdiagnosis. We reviewed alternative approaches for diagnosis of 5ARD. METHODS We conducted a retrospective review of the results of urinary steroid profiling (USP) by GC-MS and mutational analysis of SRD5A2 [steroid-5-alpha-reductase, alpha polypeptide 2 (3-oxo-5 alpha-steroid delta 4-dehydrogenase alpha 2)] by PCR and direct DNA sequencing of all 46,XY DSD patients referred to our laboratory with biochemical and/or genetic findings compatible with 5ARD. We also performed a literature review on the laboratory findings of all 5ARD cases reported in the past 10 years. RESULTS Of 16 patients diagnosed with 5ARD between January 2003 and July 2012, 15 underwent USP, and all showed characteristically low 5α- to 5β-reduced steroid metabolite ratios. Four patients had DHT measured, but 2 did not reach the diagnostic cutoff. In all 12 patients who underwent genetic analysis, 2 mutations of the SRD5A2 gene were detected to confirm the diagnosis. Twenty-four publications involving 149 patients with 5ARD were published in the review period. Fewer than half of these patients had DHT tested. Nearly 95% of them had the diagnosis confirmed genetically. CONCLUSIONS 5ARD can be confidently diagnosed by USP at 3 months postnatally and confirmed by mutational analysis of SRD5A2. Interpretation of DHT results may be problematic and is not essential in the diagnosis of 5ARD. We propose new diagnostic algorithms for 46,XY DSD.

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In Children with 46, XY DSD; HCG Testing Is Not Always the Best Answer for Testicular Function Assessment

10.21203/rs.3.rs-743544/v1 ◽

2021 ◽

Author(s):

Shaymaa Raafat ◽

Doaa Khater

Keyword(s):

Disorders Of Sex Development ◽

Serum Testosterone ◽

Inhibin B ◽

Stimulation Test ◽

Testicular Function ◽

Non Invasive ◽

Sex Development ◽

Before And After ◽

And Function

Abstract Hormonal levels are the hallmark for the assessment of testicular function in XY DSD (Disorders of sex development). Traditionally, it has relied on testosterone level increment after hCG (human chorionic gonadotropin) stimulation testing. More recently role of Sertoli cell hormones is more emphasized.Objectives: Evaluating the role of serum anti-mullerian hormone and inhibin B on function of the pre-pubertal testis without the need for hCG stimulation test.Method: The study was conducted in the Endocrinology Clinic in Alexandria University Children's Hospital. All patients who present with XY DSD were tested for testosterone (T), dihydrotestosterone (DHT), Follicle stimulating hormone (FSH), luteinizing hormone (LH), anti-mullerian hormone (AMH), inhibin B. All cases had hCG stimulation test.Results: The hCG stimulation test was done for 32 cases. There was significant positive correlation between serum testosterone levels before and after hCG stimulation test (p <0.001). Similarly, significant correlation was identified between basal AMH and testosterone increment after hCG stimulation (p <0.001) and between basal levels of AMH and inhibin (MCp= 0.025).Conclusion: Single measurement of basal AMH and/or inhibin B can detect the presence and function of testes by a reliable non-invasive way. Basal AMH assessment is an important tool to distinguish between cryptorchidism and anorchia. hCG test is needed in the work-up of patients with inconclusive results.

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Testicular function and physical outcome in young adult males diagnosed with idiopathic 46 XY disorders of sex development during childhood

Acta Endocrinologica ◽

10.1530/eje-11-0588 ◽

2011 ◽

Vol 165 (6) ◽

pp. 907-915 ◽

Cited By ~ 15

Author(s):

Thomas Blanc ◽

Ahmed Ayedi ◽

Alaa El-Ghoneimi ◽

Hendy Abdoul ◽

Yves Aigrain ◽

...

Keyword(s):

Disorders Of Sex Development ◽

Serum Testosterone ◽

Clinical Findings ◽

University Hospital ◽

Testicular Function ◽

Adult Males ◽

Testosterone Treatment ◽

Sex Development ◽

Penis Length

ObjectiveThere are few studies of outcome in male patients with undefined 46 XY disorder of sex development (DSD). We aimed to assess testicular function and clinical characteristics after puberty in men with idiopathic 46 XY DSD.DesignWe conducted a University Hospital-based observational follow-up study.MethodsNineteen patients with severe hypospadias associated with other signs of defective virilization, such as microphallus, cryptorchidism, and/or bifid scrotum, who were initially managed during childhood between 1988 and 1994, were evaluated at a median age of 17.6 (16.3; 17.8) years. Outcome measures included clinical findings and serum testosterone, FSH, LH, and inhibin B concentrations.ResultsTesticular function was normal in only five (26%) patients. Impaired testicular function was observed in 14 (74%) patients and was partial (n=6; 32%) or total (n=8; 42%), requiring testosterone treatment for the initial (n=2) or secondary (n=6) induction of puberty. Undescended testis (unilateral n=3, bilateral n=2) was found and surgically managed only in the 14 patients with testicular impairment. Testosterone treatment in early childhood greatly increased penis length in all patients, but persistent microphallus following surgical treatment was observed at the end of puberty in most patients, with no difference between patients with and without testicular dysfunction (penis length of 68 (60; 75) vs 65 (60; 65) mm; P=0.42). Half the patients presented an adult height more than 5 cm below their target height.ConclusionMen diagnosed with idiopathic 46 XY DSD during childhood are at high risk of testicular insufficiency and persistent micropenis, and this should be taken into account during the follow-up.

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New insights into 5α-reductase type 2 deficiency based on a multi-centre study: regional distribution and genotype–phenotype profiling of SRD5A2 in 190 Chinese patients

Journal of Medical Genetics ◽

10.1136/jmedgenet-2018-105915 ◽

2019 ◽

Vol 56 (10) ◽

pp. 685-692 ◽

Cited By ~ 2

Author(s):

Baoheng Gui ◽

Yanning Song ◽

Zhe Su ◽

Fei-Hong Luo ◽

Linqi Chen ◽

...

Keyword(s):

Regional Distribution ◽

Clinical Manifestations ◽

Disorders Of Sex Development ◽

Chinese Patients ◽

Compound Heterozygous ◽

Multi Centre Study ◽

Proximal Hypospadias ◽

Sex Development ◽

Distal Hypospadias

BackgroundThe 5α-reductase type 2 (5α-RD2) deficiency caused by mutations in the steroid 5α-reductase 2 (SRD5A2) gene results in variable degrees of undervirilisation in patients with 46,XY disorders of sex development. This study aims to profile the regional distribution and phenotype–genotype characteristics of SRD5A2 in a large Chinese 5α-RD2 deficiency cohort through multi-centre analysis.Methods190 subjects diagnosed with 5α-RD2 deficiency were consecutively enrolled from eight medical centres in China. Their clinical manifestations and genetic variants were analysed.ResultsHypospadias (isolated or combined with microphallus and/or cryptorchidism) was fairly common in the enrolled subjects (66.32%). 42 variants, including 13 novel variants, were identified in SRD5A2. Homozygous and compound heterozygous mutations presented in 38.42% and 61.58% of subjects, respectively, and predominated in exons 1, 4 and 5. The most prevalent variant was c.680G > A (52.37%), followed by c.16C > T, (10.79%), c.607G > A, (9.21%) and c.737G > A, (8.95%). However, their distributions were different: c.680G > A was more common in South China than in North China (62.62% vs 39.16%, p < 0.001), whereas the regional prevalence of c.16C > T was reversed (6.07% vs 16.87%, p = 0.001). Furthermore, c.680G > A prevailed in cases with normal meatus (68.75%) or distal hypospadias (66.28%), compared with those with proximal hypospadias (35.54%, p < 0.001). However, cases with proximal hypospadias showed a higher frequency of c.16C > T (20.48%) than those with normal meatus (3.13%) or distal hypospadias (3.49%, p < 0.001).ConclusionsThis study profiled variable phenotypic presentation and wide mutational spectrum of SRD5A2, revealing its distinctive regional distribution in Chinese patients and further shaping the founder effect and genotype–phenotype correlation of SRD5A2.

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Clinical, hormonal, and molecular-genetic characteristics of three cases of 46XY disorder of sex development caused by type II 5-alpha reductase deficiency

Problems of Endocrinology ◽

10.14341/probl201056334-40 ◽

2010 ◽

Vol 56 (3) ◽

pp. 34-40 ◽

Cited By ~ 1

Author(s):

A A Kolodkina ◽

M E Karmanov ◽

N Iu Kalinchenko ◽

A N Nizhnik ◽

M A Nokel' ◽

...

Keyword(s):

Sexual Differentiation ◽

Molecular Genetic ◽

Diagnostic Value ◽

Male Gender ◽

Type Ii ◽

Genetic Characteristics ◽

Reductase Deficiency ◽

Sex Development ◽

Srd5a2 Gene ◽

Androgen Resistance

Deficiency of type II 5-alpha reductase (5-ARII) is known to be responsible for abnormal sexual differentiation in boys. Of primary importance is differential diagnosis between this condition and incomplete form of androgen resistance. In the latter case, adaptation to male gender is highly undesirable because of inefficiency of androgen therapy. In contrast, such adaptation is socially justified in patients with type II 5-alpha reductase deficiency; sometimes, it permits to preserve fertility. The cases reported in this paper demonstrate low diagnostic value of the T/DHT ratio (at least as determined by the immunoenzyme assay) and emphasize the necessity of analysis of the SRD5A2 gene in all patients with suspected deficiency of type II 5-alpha reductase.

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