This case report describes a 22-year-old female and her sister who presented with primary amenorrhea, sexual infantilism, and hypertension. Laboratory tests found elevated FSH and LH with low estrogen levels, consistent with ovarian failure. Genetic testing identified a mutation in the CYP17 gene in both siblings and their parents, indicating they have combined 17α-hydroxylase/17,20-lyase deficiency. This rare condition results in impaired production of cortisol, androgens, and estrogens, causing the signs and symptoms seen in these patients. Treatment involves glucocorticoid replacement and gonadal hormone therapy.

1. Reproductive Endocrine Case Conference Nov 16, 2009

2. History 22 year old G0 female primary amenorrhea sexual infantilism Consanguineous parents

3. Physical Exam Height: 5’ 2” Weight: 123 lb Blood pressure: 170/105 mm Hg Tanner Stage 1 Breasts Tanner Stage 1 Pubic Hair Normal female genitalia

4. Causes of Amenorrhea Anatomical Defects Ovarian Failure Chronic Anovulation Estrogen present Estrogen absent

6. Labs 42 mIU/mL FSH 30 mIU/mL LH <10 pg/mL E2 PRL 10 ng/mL

8. Ovarian failure (hypergonadotropichypogonadism) Gonadal agenesis Gonadaldysgenesis Abnormal karyotype Turner syndrome 45,X Mosaicism Normal karyotype Pure gonadaldysgenesis 46,XX 46, XY (Swyer syndrome)

9. Ovarian Failure (cont.) Ovarian enzymatic deficiency 17 a-Hydroxylasedeficiency 17,20-Lyase deficiency Premature Ovarian failure (POF) Idiopathic premature aging Injury Mumps oophoritis, radiation, chemotherapy

10. Ovarian Failure (cont.) Premature Ovarian failure (POF) Resistant ovary Idiopathic Mutations of FSH receptor Mutations of LH receptor Autoimmune disease Galactosemia

11. First test in gonadal failure when FSH>40mIU/mL?

12. Karyotype 46 XX

13. Radiography Abdominal CT scan showed bilateraladrenal hyperplasia, small uterus measuring 29 and 13 mm inthe diameters, and 4 cm cyst on the left ovary

14. Laboratory Analysis Serum sodium, blood urea nitrogen, and creatinine were normal Serum potassium level was 2.87 mmol/liter

15. Family History-Sibling Family history revealed that the patient’ssister also suffered from primary amenorrhea, sexual infantilism,and hypertension. At the time of diagnosis, she was 17 yr old, she had been admittedto another hospital because of inguinal pain and presence oflumps in inguinal regions bilaterally.

16. Sibling Both inguinal masseswere removed, and pathological examination revealed testes. Based on these findings, the absence of pubic andaxillary hair and the 46,XY karyotype, the diagnosis of androgeninsensitivity syndrome was made.

17. Physical Exam - Sibling Physical exam revealed female infantileexternal genitalia and a complete absence of sexual hair andbreast development. Blood pressure: 155/110 mm Hg.

18. Laboratory Analysis - Sibling Serum sodium,blood urea nitrogen, and creatinine were normal Serum potassiumlevel was 2.66 mmol/liter

19. Radiography - Sibling AbdominalCT scan revealed bilateral adrenal hyperplasia,whereas müllerian structures were absent.

20. Plasma Steroids - Sibling AM Cortisol ACTH StimCortisol Progesterone DHEA Androstenedione Testosterone Estradiol 8.1 µg/dL 12.3 µg/dL 10.7 ng/mL < 3 ng/mL < 3 ng/dL < 20 ng/dL < 10 pg/mL

21. Plasma Steroids - Patient AM Cortisol ACTH StimCortisol Progesterone DHEA Androstenedione Testosterone Estradiol 6.2 µg/dL 7.3 µg/dL 12.0 ng/mL < 3 ng/mL < 3 ng/dL < 20 ng/dL < 10 pg/mL

22. Plasma Steroids - Parents Both parents were tested and found to have a normal steroidogenic profile with a normal response to ACTH stim testing.

23. Diagnosis Combined 17 a-hydroxylase/17,20-lyasedeficiency syndrome (17-OHDS)

24. Urinary Steroids Inboth patients, levels of the urinary metabolites of pregnenolone, progesterone, and corticosteronewere increased above normal. Levels of the urinary metabolitesof 17-hydroxypregnenolone, 17-hydroxyprogesterone,and cortisolandrostenedione, T, E2, and DHEA were low to undetectable.

26. CYP17 The CYP17 gene has been studied in more than 30 patients, and a total of 20 different mutations have been identified in its coding region Complete absence of 17alpha-hydroxylase/17,20-lyase activity has resulted from a variety of mutations, including single-base-pair changes resulting in missense mutations, duplications, deletions, and premature translational termination

27. CYP17 Mutations

28. Molecular analyses The CYP17gene was screened for mutations by direct sequencing of the coding region. A missense mutation (T278G) responsiblefor Phe93Cys amino acid substitutions in the codingregion of exon 1 was found in both siblings. Additionally, both consanguineous parents were found to be heterozygous for this mutation.

29. Molecular analyses The importance of Phe93 is supportedby the observation that this amino acid is conserved in allthe P450c17 enzymes characterized to date, including horse,sheep, bovine, guinea pig, rat, mouse, rainbow trout, dogfish,chicken, and frog T278G was absent in 50 unaffected,unrelated control individuals

31. Treatment Therapy withdexamethasone was started, followed by the addition of conjugatedestrogens. On dexamethasone therapy, plasma renin activity (PRA)and potassium levels increased to normal and blood pressureand blood pH fell to normal

32. CYP17 13 kb long eight exons chromosome 10 at 10q24-q25 adrenals and gonads

33. CYP17 Deficiency 17alpha-Hydroxylase deficiency is a rare autosomal recessive disorder that occurs in approximately 1 of 50,000 individuals More than 130 cases have been reported It was initially reported by Biglieri and colleagues in 46,XX females who had hypertension, hypokalemia, and sexual infantilism Subsequently, this defect was described in 46,XY male infants, children, and adults with 46 XY DSD.

34. CYP17 Two types of enzymatic deficiency causing this rare form of CAH have been reported: combined deficiency of 17alpha-hydroxylase and 17,20-lyase isolated 17,20-lyase deficiency The combined form is most common

35. Isolated 17, 20-lyase deficiency Women with isolated 17,20-lyase deficiency would be expected to have sexual infantilism with lack of adrenarche and elevated gonadotropins at puberty resulting from an inability to synthesize both androgens and estrogens in the adrenals and gonads There should be no defect in cortisol synthesis and no mineralocorticoid (DOC) excess and hypertension

36. Combined CYP17 Deficiency A defect in 17 alpha-hydroxylation in both the adrenal cortex and gonads results in impaired synthesis of 17-hydroxyprogesterone and 17-hydroxypregnenolone and thus of cortisol, androgens, and estrogens Decreased cortisol synthesis causes increased corticotropin secretion, which results in excessive secretion of 17-deoxysteroids by the adrenal cortex, including the mineralocorticoid DOC, corticosterone, and 18-hydroxycorticosterone

37. CYP17 Excess DOC secretion leads to hypertension, hypokalemic alkalosis, and suppression of the renin-angiotensinsystem. Corticosterone is a weak glucocorticoid; the high plasma concentrations in this disorder prevent the signs and symptoms of cortisol deficiency and modulate the secretion of corticotropin

39. CYP17 17alpha-Hydroxylase deficiency is usually recognized at the time of expected puberty in the female because of the presence of hypertension and/or hypokalemia associated with hypergonadotropichypogonadism Affected 46,XX females have normal female internal and external genital tracts, but the ovaries cannot secrete estrogens at puberty, resulting in sexual infantilism and hypogonadism with elevated plasma FSH and LH levels

40. CYP17 Deficiency In addition, the lack of adrenal and ovarian androgens can result in little or no growth of pubic and axillaryhair. In affected 46,XX individuals the ovaries have a high proportion of atretic follicles and some ovaries contain an increased number of enlarged follicular cysts.

41. CYP17 Deficiency The phenotype of 46,XY males with 17alpha-hydroxylase deficiency varies from that of an individual with normal-appearing female external genitalia or sexual ambiguity The magnitude of the impaired masculinization in the male fetus correlates with the severity of the block in 17alpha-hydroxylation and the magnitude of the consequent impairment in fetal testosterone synthesis

42. CYP17 Deficiency The testes may be intra-abdominal, in the inguinal canal, or in the labioscrotal folds. Inguinal hernias are commonly present Mullerianstructures are absent, and wolffian derivatives are usually hypoplastic

43. CYP17 Analysis of these patients suggests that 5% of normal activity in a 46,XX female is sufficient to allow estrogen production with normal secondary sexual characteristics and irregular menses, whereas more than 25% of normal activity appears to be necessary to achieve normal virilization of the external genitalia of affected 46,XY males

44. Treatment Replacement therapy with physiological doses of glucocorticoids suppresses DOC and corticosterone secretion . With suppression of the excess circulating mineralocorticoids, the blood pressure serum potassium level return to normal At puberty, both affected males and affected females will require gonadal steroid replacement

45. Fertility Limited data from case reports have shown that successful pregnancies in women with 17-alpha-hydroxylase deficiency can be achieved. I Ben-Nun Human Reproduction, Vol 10, 2456-2458 1995

46. THE END

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