Erbolato Gabiatti Maciel-Guerra Erisvaldo Ferreira Cavalcante-Junior Arq Bras Metab. Endocrinol 2012;56/8 T INTRODUCTION Cristina Carla Telles deSousaCastro de 17b Espectro clínico emoleculardepacientes comdeficiência (17-β-HSD3) deficiency dehydrogenase type3 of patientswith17b-hydroxysteroid Clinical andmolecularspectrum dos casos 1, 2 e 4, respectivamente. to dogeneHSD17B3 doscasos1,2e4,respectivamente. p.Ala203Val, p.Gly289Ser, p.Arg80Gln foramidentificadasemhomozigosepelosequenciamen do íntron3geneHSD17B3 , foiidentificadanocaso3. Além dessas,asmutaçõesmissense ção nova c.277+2T>G e damutaçãoc.277+4A>T, ambaslocalizadasnosítiodoadordesplicing identidade degênerofemininofoimantidaemtodaselas. A heterozigosecompostadamuta de sinaisvirilizaçãonapuberdade. Todos ospacientesforamcriadoscomomulheres,ea androstenediona <0,8.Emtrêsdaspacientes,odiagnóstico foi suspeitadodevidoàpresença graus,androstenedionaaumentada,testosteronadiminuída,erelação diversos latados quatrocasosdedeficiênciada 17-β-HSD3 comcariótipo46,XY, ambiguidadegenitalem de característicasfenotípicaseresultadosdosagenslaboratoriais. Nestetrabalho,sãore do desenvolvimento 46,XY. dosexo emindivíduos A desordemapresentaumamploespectro drostenediona atestosteronanostestículos,esuadeficiênciaéumaformararadedistúrbio A enzima17β-hidroxiesteroide desidrogenasetipo3(17-β-HSD3) catalisaaconversãodean SUMÁRIO HSD17B3 genesequencingincases1,2,and4,respectively. mozygosis forthemissensep.Ala203Val, p.Gly289Ser, p.Arg80Glnmutationswerefoundupon the intron3splicedonorsiteofHSD17B3 ,wereidentifiedincase3.Inaddition,ho heterozygosis for c.277+2T>G novel mutation, and c.277+4A>T mutation, both located within been raisedasfemales,andfemalegenderidentitywas maintainedinallofthem.Compound nosis was onlydeterminedduetothepresenceofsignsvirilizationatpuberty. All patientshad tosterone levels,andtestosteronetoandrostenedioneratio<0.8.Inthreeofthepatients,diag showing different degreesofgenitalambiguity, increasedandrostenedioneanddecreasedtes hormonal profiles. We reportkaryotype and 17- fourpatientswiththe46,XY β Itcanleadtoawiderangeofphenotypicfeatures,withvariable opment in46,XYindividuals. totestosteroneinthetestes,anditsdeficiencyisararedisorderofsexdevel The enzyme17β SUMMARY Flavia LemeCalais Regina Ferreira Pereira nase type3(OMIM *605573,17-β-HSD3),also dehydroge he isoenzyme17β-hydroxysteroid -hidroxiesteroide desidrogenase tipo2(17-β -hydroxysteroid dehydrogenase type3(17-β 6,8 , Palandi Maricilda DeMello 7 , Antonia Paula Marques-de-Faria 2 , Fernanda Borchers Coeli 3 , Roberto Benedito dePaiva eSilva 4 , IsabellaLopes Monlleó 1 , Guaragna-Filho Guilherme 2 , GilGuerra-Junior 2 , IanikRafaela LimaLeal Arq BrasEndocrinolMetab. 2012;56(8):533-9 - -HSD3) catalyzes theconversionof Arq BrasEndocrinolMetab. 2012;56(8):533-9 6,8 ,Andrea Trevas one (Δ4), to the more biologically active biologically active testosterone one (Δ4), to the more substrate, androstenedi version of the weak known as 17-ketosteroid reductase, catalysesthecon reductase, known as17-ketosteroid -HSD3) 5,6 , José Roberto 4 , Silma 1,6 -HSD3 deficiency,

1 , 3 , ------Campinas, SP, Brazil de Campinas(Unicamp), Médicas, Universidade Estadual Pediatria, Faculdade deCiências Pediátrica, de Departamento Campinas, SP, Brazil Médica, FCM-Unicamp, FCM-Unicamp, Campinas,SP, Brazil Unicamp, Campinas,SP, Brazil do Sexo (GIEDDS),FCM- da DeterminaçãoeDiferenciação Campinas, SP, Brazil Reabilitação, FCM-Unicamp, Desenvolvimento Humanoe (UFAL), Maceió, AL, Brazil Universidade Federal de Alagoas (UFMA), SãoLuís,MA,Brazil Universidade Federal doMaranhão Campinas, SP, Brazil Genética (CBMEG),Unicamp, Biologia MoleculareEngenharia Molecular Humana,Centrode 1 Accepted onSept/20/2012 Receivedon Aug/2/2012 [email protected] 13083-100 –Campinas,SP, Brazil FCM-Unicamp dePediatria,Departamento Gil Guerra-Junior Correspondence to: 8 7 6 5 4 3 2 Unidade deEndocrinologia Departamento deGenética Departamento de Tocoginecologia, Departamento Grupo InterdisciplinardeEstudos de Departamento Centro deCiênciasdaSaúde, deBiologia, Departamento Laboratório deGenética case report 533 - -

Copyright© ABE&M todos os direitos reservados. Copyright© ABE&M todos os direitos reservados. 534 mutations alsoidentified inthispaper, andthe#shows themutationidentifiedherefor the firsttime. Figure 1. HSD17B3geneisrepresentedwithits11exons. Mutationsfoundin17-b-HSD3deficiencyareindicated. Blackboxeshighlightrecurrent (4-9,12,13). asmalesafterpuberty reassigned males developamalegenderidentity, anddecidetobe 17-β-HSD3 activity(11).Manyindividualsraisedasfe extragonadal 17-β-HSDisoenzymes,orduetoresidual due totheconversionofabundantΔ4Tbyother genitaliaoccurs.Thisisprobably tion oftheexternal (10), when viriliza undetectableuntilpuberty remains withfemalegenitalia,andthedisorder usuallyborn are 46,XYindividuals affected or compoundheterozygous forthedisease,inwhichhomozygous responsible are (4-9).MutationsintheHSD17B3gene talia atbirth geni gion, andfemaleexternal within theinguinalre testes genitalia, absent or hypoplastic prostate, ternal in entiation, characterizedbyhypoplastic-to-normal ofmalesexdiffer form disorder autosomal recessive 11 exonsandislocatedon9q22(1-3). lia. Thehumangene,designatedHSD17B3,contains genita andexternal fetal developmentofmaleinternal (T) inthetestes.Thisconversionisessentialfornormal 17-β-HSD3 deficiency upon virilization of affected individuals(7,14). upon virilizationofaffected willonlybediagnosedatpuberty hood, thedisorder test. Intheabsenceofsuggestivesignsduringchild- tohCGstimulation isapoorresponse tion, there inaT/Δ4ratiolowerthan 0.8.Inaddi- that result levels be established by elevated Δ4 and low T serum ofTbiosynthesis.Diagnosiscan and otherdisorders sensitivity syndrome, 5 sensitivity syndrome, in- androgen partial clinically indistinguishablefrom 17- -HSD3 deficiency (OMIM #264300) is a rare 17-β-HSD3 deficiency(OMIM#264300)isarare β -HSD3 deficiency in prepubertal patientsis -HSD3 deficiencyinprepubertal α -reductase type 2 deficiency,-reductase # ------ucts was carried outusingtheWizard ucts wascarried - PurificationofPCRprod availableuponrequest. are with Prime3primerdesigningtool;sequences chosen (PCR). Primers used for PCR were reaction amplifiedbypolymerasechain HSD17B3 genewere junctionsequencesof 11 exonsandexon/intron K/phenolextractionmethod(17).The by proteinase peripheralblood Genomic DNAwasobtainedfrom MATERIALS ANDMETHODS tures offourcases17- tures scripts, andoneduplicationofexons3-10(4,15,16). tran- located atsplicejunctionsleadingtoaberrant stopcodon,four premature leading todownstream missenses, onenonsensemutation,twoframeshifs 1),including21 gene havebeenidentified(Figure CLC Sequence Viewer v.6.2CLC SequenceViewer software). (free and software) version-free (reduced using Chromas tisense primers was performed usingBigDye tisense primerswasperformed PCRfragmentsequencingwithsenseandan- Direct Madison,WI,USA). PCR clean-up system (Promega, mal sequence(ENSEMBL withtheHSD17B3 compared tems), andwere ABI 3130 DNAAnalyzer(ABIPRISM/PEBiosys- obtainedinanautomatic sequencer Sequences were (ABI PRISM/PEBiosystems,FosterCity, CA,USA). minator CycleSequencingKitV3.1ReadyReaction Here, we report theclinicalandmolecularpic- wereport Here, To date,atotalof29mutationsintheHSD17B3 Arq Bras Metab. Endocrinol 2012;56/8 β -HSD3 deficiency. –

ENSG00000130948) ENSG00000130948) ® SV Gel and SVGeland ® Ter nor - -

Arq Bras Metab. Endocrinol 2012;56/8 hia (Ba- OliveiradosBrejinhos A 4‐year‐oldgirl,from Case 2 A 16-year-old Pariconha(Alagoas girlfrom Case 1 CA re 3B).Herfamilydecid ed tomaintain thefemale re for thep.Gly289Sersubstitution inexon11(Figu­ HSD17B3 genesequencingshowed homozygosis shown intable1. dataare Laboratory karyotype. Cytogeneticanalysis indicateda46,XY observed. were lateral palpablegonadswithin inguinalregion fusion,andbi - single perinealopening, labioscrotal was 16.2kgandheight102cm.A3.7-cmphallus, ful pregnancy. Atphysicalexamination,herweight afteranunevent- atterm andwasborn neous parents, gonads. Shewasthesecondchildofnon-consangui­ to usinvestigategenitalambiguitywithpalpable as soonshedecidestoinitiatesexualactivity. the femalegender, vaginaldilationwillbeperformed Asshemaintained peritubularfibrosis. with discrete testes analysis ofbothgonadsindicatedpubertal was administrated. The with estrogens replacement andhormonal performed, ing genitoplastywere female gender. Bilateralgonadectomy andfeminiz- patient andthefamily, theydecidedtomaintainthe 3A).Afterpsychologicalevaluationofthe (Figure gous p.Ala203Val missensemutation withinexon9 the homozy- HSD17B3 gene sequencing revealed shownintable1. dataare 46,XY andlaboratory was 2Aand2B).The karyotype pubic hair(Figures velopment Tanner andTanner 3forbreasts, 5for de- facialhairand pubertal addition, shepresented In alsoobserved. vaginawere opening withashort the leftgonad,respectively. Asingleperinealurethral with volumesof15cm folds cm phallusandpalpablegonadsinlabioscrotal a5.7- genitaliapresented 168.4 cm,respectively; 68kgand amination, herweightandheightwere genitoplasty doneduringchildhood.Onphysicalex- whohadbothgonadectomyand absence ofuterus, and amenorrhea showedasisterwithprimary history consanguineous (second cousins), and family were old mother, andweightedover4.5kg.Herparents sectiontoa48-year- bycesarean atterm was born genital ambiguityandvirilizationatpuberty. She tousdue ofBrazil)wasreferred region eastern SE REPORTS – gion of Brazil), was referred gion ofBrazil),wasreferred re Northeastern 3 and 10cm 3 fortherightand – - North

sanguineous tion atpuberty. Shewasthesecondchildofacon- to us duetogenitalambiguityandviriliza- brought A 13‐year‐old girl from SãoLuís(Maranhão A 13‐year‐oldgirlfrom Case 3 Grosso Grosso Altodo Araguaia (Mato A 14‐year‐oldgirlfrom Case 4 of the gonads showed normal pre‐pubertal testes. pre‐pubertal of thegonadsshowednormal Histologicalanalysis performed. were introitoplasty gender. gonadectomy, Therefore, clitoroplasty, and dence ofmalignancy. cell aplasia,andLeydighyperplasia,withoutevi- germ- bilateral testeswithslightperitubularfibrosis, tion. Histologicexaminationofbothgonadsshowed ment therapywasinitiated,followedbyvaginaldila- - replace thegonads,andestrogen toremove formed was per psychological evaluation, video laparoscopy bylong-term female genderidentitywasconfirmed hermother(datanot shown).After the secondfrom herfather,the first variantwas inherited from and 3C).Theanalysisofthefamilyindicatedthat (Figure sequence, c.277+4A>T, andthenovelc.277+2T>G 3splicedonnor consensus changes withinintron for two nucleotide quencing showed heterozygosis HSD17B3genese- found attheinguinalregion. identified,andbothgonadswere inal vesicleswere However, oraprostate. sem- did notshowanuterus shown intable1.MRIoftheabdomen and pelvis type was46,XY. evaluationare Resultsofhormonal - 2C and 2D). Karyo palpable (Figures gonads were stage 4.Hervaginaendedina3-cmpouch,andno PubichairwasTanner pigmentedandrugged. were folds largement (3.7cm),andtheskinoflabioscrotal hair on the abdomen and face, phallus en- increased Tanner were 59.8 kg.Herbreasts stage1.Shehad amination, thepatientwas164cmtallandweighed withoutsexambiguity.one brother Onphysicalex- andwithoutsignsofvirilization, with telarche, tuna andBuritiBravo).Shehadtwosisters,both small cities Maranhão State (For eous, and from nancy. healthy, were Herparents non-consanguin- - afteranuneventfulpreg atterm 11. Shewasborn deepening, andphallusenlargement sincetheageof signs ofvirilizationsuchasacne,hirsutism,voice tousdue ofBrazil)wasreferred region eastern – Central-Western ofBrazil) was region marriage (first cousins). Family history (first cousins). Familyhistory marriage 17-β-HSD3 deficiency – - North 535 - -

Copyright© ABE&M todos os direitos reservados. Copyright© ABE&M todos os direitos reservados. A C 536 – figuresAandB, andcase 3–figuresCand D. Figure 2. ExternalgenitaliaofpatientswithHSD17B3 deficiency. Case1 patient decidedtopostponevaginaldilation. therapywasinitiated,and the replacement Estrogen testes. pubertal cal gonadalanalysisindicatednormal Histologi- performed. feminizing genitoplastywere gonadectomy and tain thefemalegender;therefore, 3D).Thepatientdecided tomain- in exon3(Figure ing showedhomozygosisforp.Arg80Gln mutation vagina.HSD17B3genesequenc- sinus withashort Genitographyshowedaurogenital oraprostate. rus table 1.Pelvicultrasonographydidnotshowaute­ was 46,XY. shown in evaluation data are Hormonal as wellTanner development.Karyotype 3breast dominal, andpubichair(Tanner observed, 3)were ofinguinalcanal.Facial,axillary,lower third ab- pigmentation, andbilateralpalpablegonadsin the foldswith fusionoflabioscrotal al opening,partial 41.4 kg.Shehada4.5-cmphallus,singleperine- amination, thepatientwas160cmtallandweighed cousinwithhirsutism.Uponphysicalex- paternal clitoromegaly,presented anda12-year-old female showed a2-year-old cou­ femalematernal 17-β-HSD3 deficiency D B sin who We fourcases of17- here report DISCUSSION arginine byglutamine(p.Arg80Gln). case 4;thissubstitutioncausesthereplacementinresidue80, usually Homozygous CGG>CAnucleotidechangewithinexon3identifiedin red arrowindicatesthebeginningofIVS3atexon3/intron3boundary. D) are within the donorsplice site consensussequenceofintron 3; theempty mother andthefather, respectively(datanotshown);thetwomutations c.277+4A>T nucleotide changes in case 3, which were inherited from the p.Gly289Ser. causes thereplacementinresidue289, usuallyglycinebyserine nucleotide changewithinexon11identifiedincase2;thissubstitution 203, usuallyalanine, byvaline(p.Ala203Val). B)HomozygousGGT>AGT identified incase1;thissubstitutioncausesthereplacementresidue sequencing: Figure 3. PartsoftheeletropherogramsobtainedforHSD17B3gene parents (cases1and4), andshowedhomozygosis parents to consanguineous born were cases described here (20).Two outofthefour consanguineous marriages of 1:100 to1:300,dueahighfrequency from lence ishigheramongthe Arab population,ranging - biosynthesis(4).Itspreva testosterone that affects of46,XYDSD form in 1971(18,19).Itisarare thatwasdescribedforthefirsttime disorder a rare D B A C A) HomozygousGCG>GTnucleotidechangewithinexon9 C) Compoundheterozygosisforc.277+2T>Gand Arq Bras Metab. Endocrinol 2012;56/8 β -HSD3 deficiency,

17- tients may present virilization at puberty (4,5,7). virilization atpuberty tients maypresent pa- childhood, andgonadectomy isnotperformed, NP: notperformed; T: testosterone. Arq Bras Metab. Endocrinol 2012;56/8 activityofmutated17- withpartial correlate pospadias (4-8).Thisvariabilityinphenotypesmay andhy- dominantly malegenitaliawithmicrophallus - with palpable gonads,as in cases 1 and 4; to pre genitalia, asincase2;toevidentgenitalambiguity male genitalia,asincase3;tomildvirilizedfemale fe- predominantly from individuals. Thesemayvary range ofphenotypiccharacteristicsto46,XYaffected oftheStateBahia. small cityofthecountryside ata born were this case,thepatientandherparents a homozygousmutationintheHSD17B3 also showed who has non-consanguineous parents, for # * After 3consecutivedaysof1,500IUintramuscularhumanchorionicgonadotropin; Table 1. HormonalprofileoffourcaseswithHSD17B3deficiency to Tbyother17- in thetestes,ortoanextragonadalconversionofΔ4 degree of virilization with palpable gonads (4,5,7). ofvirilization withpalpablegonads(4,5,7). degree duringchildhood duetosome they seekmedicalcare versely, some cases may be diagnosed early, because for most patients (4-8). Con- established at puberty diagnosisisonly raised asfemales(4,5,8).Therefore, and registered andare nosis of46,XYDSDatbirth, female genitalia,mostpatientsdonothavethediag- pre-pubertal malereferencerange;Δ4: androstenedione;E1: ;E2: estradiol; E2/E1 ratio T/Δ4 ratio T/DHT ratio DHEA sulfate(μg/mL) E2 (pg/mL) E1 (pg/mL) LH (IU/L) Puberty DHT (ng/mL) Age (years) Δ4 (ng/mL) T (ng/mL) FSH (IU/L) As the most common clinical presentations of of As themostcommonclinicalpresentations Different Different If 17- β HSD17B3 mutations.Ontheotherhand,case2, -HSD3 deficiency are female or mild virilized femaleormildvirilized -HSD3 deficiencyare β -HSD3 deficiencyisnot diagnosedin HSD17B3 gene mutations confer a wide β -HSD isoenzymes(11). Case 1 0.65 0.62 20.9 32.1 12.1 0.49 8.6 3.8 6.8 4.2 7.4 16 + Case 2 0.21* 0.61 3.8* 1.3* 0.8* β gene. In 1.9 0.4 2.0 NP NP NP 4 - -HSD3 -HSD3 than a normal-sized penis(4,5,7). than anormal-sized version. However, the phallus will always be shorter toperipheralTcon- inresponse also beobserved 5-8cminlength, whichmay elongation reaching fatdistribution,inaddition tophallus and android all overthebodyandface,deepeningofvoice, hairgrowth increased Main signsofvirilizationare 17- trations (4,5,7).WhenT/Δ4ratioislessthan0.8, concen- Δ4 and T serum high and low to normal patientshave,respectively, here, all casesreported withmolecularanalysis.Asverifiedin be confirmed investigation,andmay suspected uponlaboratory activity, humanmaledevel - normal andtopromote levelsofenzymatic critical inmaintainingappropriate shouldbe structure 80oftheprotein the Rinresidue to NADPHcofactor. itissuggestedthat Therefore, ofthemutantprotein duction inthebindingaffinity enzymeactivity,mately 5%ofresidual - anda1/60re - leadingtoapproxi in therateofenzymaticreaction strated thatp.Arg80Gln causesasignificant decrease zilian patients(6).McKeeverandcols. (21)andBra- most commononeinMediterranean notalwaysobserved. these elevatedvaluesare of DHEAandsulfate(4,5,7).However, concentrations serum toincreased alsorefers erature The diagnosisof17- The mutation p.Arg80Gln identified in case 4 is the The mutationp.Arg80Gln identified in case4isthe β Case 3 -HSD3 deficiencyissuggested(7,14).Thelit- 0.63 0.50 16.0 25.8 41.0 0.42 8.1 2.5 6.5 3.4 6.7 13 + Case 4 0.52 0.65 10.5 22.2 42.7 0.58 5.3 3.9 4.8 3.1 8.7 14 + β -HSD3 deficiencymaybe Male referencerange 17-β-HSD3 deficiency (22)demon- (12 –19yr) 17.0 -44.0 0.25 -1.20 1.4 -18.1 # # 1.0 -4.2 0.5 -5.3 0.7 -1.9 0.1 -5.0 0.8 -2.3 0.1 -1.2 < 10.0 < 50.0 > 0.8 - 537

Copyright© ABE&M todos os direitos reservados. Copyright© ABE&M todos os direitos reservados. gous for two nucleotide changes affecting intron 3 intron gous fortwo nucleotidechangesaffecting with themutation. couldactsynergistically regions change inregulatory ated withthephenotype,and someothernucleotide homozygous p.Gly289Ser incase2maybeassoci- we canspeculatethatthe regions, or 3’ regulatory (29,30).Sincewedidnotevaluateeither5’ sidered it maynotbeasneutralhadbeeninitiallycon- S289 thanforthewild-typeG289,indicatingthat significantlylowerforthemutant sion levelswere - the S289alleleinhomozygosis,oncemRNAexpres cancer, andtohypospadiasinindividualscarrying riskofdevelopingprostate associated withincreased tion, p.Gly289Seraminoacidsubstitutionhas been gene thatmayexplainthephenotype(5).Inaddi- oftheHSD17B3 regions alterations inregulatory mutation. Itwassupposedthatthispatientcarried thewell-knowndeleteriousp.Asn130Ser also carried patientwho identified inacompound heterozygous ter theinvitroenzymaticactivity. However, itwas of1,000genomes(28).Italso didnotal- screening inthe inallpopulationsreported since itisfrequent apolymorphism This mutationhasbeenconsidered substitution p.Gly289Ser(SNP–CM023631). withthephenotypeofcase1. good correlation 538 ly inactivatedtheenzyme17- Δ4intoT,for theabilitytoconvert anditcomplete- SãoPaulo–Brazil.Thismutation wasassayed from first describedbyGeisslerandcols.(26),inapatient ofthecountry. region of theNortheastern colonizersandduringtheDutchinvasion Portuguese sixteenth andseventeenthcenturiesand,inBrazil,by duringtheSpanishdominationin have occurred intheNetherlandscould (24,25). Itsintroduction 750B.C. Syria,Lebanon,andIsraelaround from andSpainbyPhoenicianswhomigrated in Portugal fact ledtothehypothesisthatithasbeenintroduced ofIsrael,Lebanon,andSyria(23).This ent regions differ commonamongArabsfrom a foundereffect, p.Arg80Gln mayrepresent mutation (5).Therefore, forthis homo-orheterozygous individuals whowere for origin, butalsoinDutchpatients,wasreported notonlyinpatientsofArab However, itsrecurrence, origin(6). ian ancestry, Portuguese andofprobable also identifiedinBrazilianfamilieswithnoPalestin- theGazaStrip(20).Further,itwas tinian familyfrom opment. ThismutationwasfirstdescribedinaPales- 17-β-HSD3 deficiency - Case 3wasfoundtobe compoundheterozy the missense Moghrabi and cols. (27) reported The p.Ala203Val mutationidentified incase1was β -HSD3, indicating a -HSD3, indicatinga - found insubjectswith17- mutations indicated itasoneofthemostprevalent intwootherfamilies.Thoseresults heterozygosis families,andin identified itinhomozygosisthree in1996byAnderssonandcols. (9),who reported Thec.277+4A>Tmutationwas splice donorregion. evaluation of the patientandfamilymembers. cided tomaintainfemaleidentity afterpsychological eventhosediagnosedatpuberty, here, de- reported sexualcharacteristics (4).Allpatients of secondary therapyforthedevelopment replacement estrogen cell tumors(32).Thesepatientsshouldreceive germ zation, butalsobecauseofthe28%riskmalignant must undergo gonadectomy not only to avoid virili­ asfemales patientswhochoosetoremain literature, tothe main inthefemalegender(4-8).According - gonadectomyre patients whoundergo prepubertal male optiontooccurisstillunclear. Conversely, most between 39%and64%(13).Theexplanationforthe varies lescence orearlyadulthood,andthefrequency 8,12,13). Suchadecisionusuallyoccursinlateado- puberty, and some may adoptthe male gender(4- before virilization ifgonadectomyisnotperformed test an aberrant splicing process inthiscase. splicingprocess test anaberrant to of mini- will be an alternative construction notaccessibleforinvitro studies,the lar samplesare splice atthatposition(datanotshown).Astesticu- donor cated that the mutation eliminated the normal NNSPLICE0.9 versionindi- Splice SitePrediction The splicesite,orleadtoexon4skipping. tivate acryptic splicingsothatitcaneitherac- thenormal suppresses probably forthefirsttime, andit was identifiedhere 3. Thismutation intron in the splicedonorsitetoGG fied incase3.ItchangesthealmostinvariantGTat scent (5).Thec.277+2T>Gmutationwasalsoidenti- likelytobeidentical byde- marker genotype,andare thesame Australians andwhiteAmericans,whoshare white tions worldwide,includingDutch,Germans, exons 3and4(5,31). minor amounts, a transcript with deletion of both exon3hadbeenskippedand,in transcript where ofcDNAsequencingshoweda patient. Theresult testis mRNA of a homozygous from cDNA prepared Boehmer andcols.(5),whoanalyzedtheHSD17B3 splicingby normal site, andwasshowntodisrupt 3canonicalsplicedonor located withintheintron Patients with17- The mutationc.277+4A>Tisfoundinpopula- search for splicing sites using the online for splicing sites using the online in silico search β -HSD3 deficiencyundergo Arq Bras Metab. Endocrinol 2012;56/8 β -HSD3 deficiency. Itis four cases of 17- gene, includingthenovelc.277+2T>Gmutation,in clinical laboratorialandpresentations. Arq Bras Metab. Endocrinol 2012;56/8 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES was reported. relevant tothisarticle nopotentialconflictofinterest Disclosure:

In conclusion, we report mutationsin HSD17B3 Inconclusion,wereport tient withsexualambiguity. JSex Med. 2012 [Epubaheadofprint]. et al. A novel nonsensemutationinHSD17B3 geneina Tunisian pa- Ben RhoumaB,BelguithN,MnifMF, Kamoun T, CharfiN, Kamoun M, (Oxf). 2000;53:697-702. stenedione ratioinmaleundermasculinization.ClinEndocrinol Faisal Ahmed S,Iqbal A, Hughes IA. The testosterone:andro- nase-3 deficiency. Arch Sex Behav. 2005;34:399-410. reductase-2 deficiencyand 17beta-hydroxysteroid dehydroge - Cohen-Kettenis PT. Gender change with 5alpha- in 46,XY persons Pediatr 2):297-306. EndocrinolMetab.2003;16(suppl D, etal.Puberty ofsomatosexualdifferentiation. indisorders J Hiort O, Reinecke S, Thyen U, Jurgensen M,HolterhusPM,Schon 2009;114:72-7. hydroxysteroid dehydrogenases. JSteroidBiochem MolBiol. Prehn C, Möller G, Adamski J. Recent advances in 17beta- women. JClinEndocrinolMetab.1999;84:802-4. Wilson JD.17Beta-hydroxysteroid dehydrogenase 3deficiencyin Mendonca BB, Arnhold IJ, Bloise W, S,RussellAndersson DW, Metab. 1996;81:130-6. hydroxysteroid dehydrogenase 3deficiency. JClinEndocrinol MI, et al. Molecular genetics and pathophysiology of 17 beta- S,Geissler Andersson WM, Wu L,DavisDL,Grumbach MM,New genase type3deficiency. JEndocrinolInvest. 2008;31:85-91. crine, andmolecularfindingsin 17beta-hydroxysteroid dehydro - Faienza MF, GiordaniL,Delvecchio M,CavalloL.Clinical,endo- (Oxf). 2007;67:20-8. drogenase-3 deficiencyanddiagnosticpitfalls.ClinEndocrinol RJ, et al. Phenotypic variability in 17beta-hydroxysteroid dehy Lee YS, KirkJM,StanhopeRG,Johnston DI,HarlandS, Auchus uation, andmanagement.Medicine(Baltimore).2000;79:299-309. teroid dehydrogenase 3deficiency. Diagnosis,psychological eval- RM, etal.Malepseudohermaphroditismdueto17beta-hydroxys - Mendonça BB,InacioM, Arnhold IJ, CostaEM,Bloise W, Martin Clin EndocrinolMetab.1999;84:4713-21. and worldwide distribution of ancient and de novo mutations. J deficiency: diagnosis,phenotypicvariability, populationgenetics, MF, S,etal.17beta-hydroxysteroidAndersson dehydrogenase-3 Boehmer AL, Brinkmann AO, Sandkuijl LA,HalleyDJ, Niermeijer Horm Res Paediatr. 2010;74:229-40. and molecularheterogeneityof17βHSD3 enzymedeficiency. George MM,NewMI, Tem S,SultanC,Bhangoo A. The clinical biology. Steroids1997;62:148-58. roleof17 beta-hydroxysteroidkey dehydrogenases insexsteroid Labrie F, Luu-The V, LinSX,LabrieC,Simard J, BretonR,etal. The crinol. 2006;248:61-71. human 17beta-hydroxysteroid dehydrogenases. MolCellEndo- P,Lukacik Kavanagh KL,OppermannU. Structureandfunctionof 17beta-hydroxysteroid dehydrogenases. .1997;62:143-47. S,Moghrabi N. Physiology Andersson andmoleculargeneticsof β -HSD3 deficiency with different -HSD3 deficiency withdifferent - 32. 31. 30. 29. 28. 27. 26. 25. 24. 23. 22. 21. 20. 19. 18. 7. 1 16.

Endocrinology.118:488-500. Pediatrics. 2006; atric EndocrineSociety andtheEuropeanSociety forPaediatric organizedConference onIntersex bytheLawson Wilkins Pedi - Lee PA, HoukCP, Faisal A, HughesIA,InternationalConsensus Pseudohermaphrodite. Fertil Steril.2008;89(1):228.e13-228.e17. JA. 17beta hydroxysteroid dehydrogenase 3deficiencyinamale Mains LM, Vakili MB, Lacassie Y, S, Lindqvistc Andersson A, Rock and theriskofhypospadias. JSex Med.2010;7(8):2729-38. Genetic polymorphismsof17 β-hydroxysteroid dehydrogenase 3 Sata F, Kurahashi N, Ban S, Moriya K, Tanaka M, et al. KD, Ishizuka 2002;53:65-8. the HSD17B3 genewithprostatecancerinItalianmen.Prostate. Association oftheG289Ssinglenucleotidepolymorphismin Margiotti K,KimE,Pearce CL,SperaE,Novelli G,Reichardt JK. ;v=rs2066479;vdb=variation;vf=16374979. Accessed on:Sept 30,2012. e;g=ENSG00000130948;r=9:98997588-99064434;t=ENST00000375263 http://www.ensembl.org/Homo_sapiens/Variation/Population?db=cor Metabol. 1998;83(8):2855-60. droxysteroid dehydrogenase 3gene(hsd17b3). JClinEndocrinol sense mutationsandsilentpolymorphisminthehuman17b-hy Moghrabi N,HughesIA,Dunaif A, S.Deleterious mis- Andersson 1994;7:34-9. of testicular17β-hidroxysteroide dehydrogenase 3.NatGenet. BB, etal.Malepseudohermaphroditismcausedbymutations Geissler WM, DavisDL, Wu L,BradshawKD,Patel S,Mendonça p. 217, 242-245,260. of humangenes.Princeton:Press; 1994. Princeton University Cavalli-Sforza LL,MenozziP, Piazza A. The historyandgeography 1991. p.461-546. Cambridge ancientyhistory, Press; 2ndEd.CambridgeUniversity J, Edwards IE,HammondNG, Sollberger E, Walker CB,eds. The Culigan W. PhoeniciaandPhoeniciancolonization.In: Boardman dehydrogenase deficiency. JClinEndocrinolMetab. 1992;75:773-8. tion inmalepseudohermaphroditismdueto17b-hydroxysteroid Rosler A, Belanger A, LabrieF. Mechanisms ofandrogenproduc- 2002;1601:29-37.phys Acta. cofator bindingandoxidation/reduction kinetics.Biochim Bio- 17 Mosley RT, etal. Amino acidsubstitutionofarginine80in Mckeever BM,HawkinsBK,Geissler WM, Wu L,SheridanRP, 3):455-61.2006;3(suppl cy in the Mediterranean population. Pediatr Endocrinol Rev. Rösler A. 17 beta-hydroxysteroid dehydrogenase 3 deficien- 1996;81:1827-31. and normalasymptomaticfemales.JClinEndocrinolMetab. of Israelisassociatedwithpseudohermaphroditisminmales beta-hydroxysteroid dehydrogenase type3geneamong Arabs Rösler S, A, Silverstein Abeliovich D. A (R80Q)mutationin17 1972;34:598-600. to a case of testicular feminization). J Clin Endocrinol Metab. due toatesticular17-ketosteroid reductasedefect(compared studies in male pseudohermaphroditism with gynecomastia Saez JM,Morera AM, DePeretti E,Bertrand J. Further invivo Endocrinol Metab.1971;32:604-10. ticular 17-ketosteroid JClin reductasedefect.I.Studiesinvivo. male pseudohermaphroditismwithgynecomastiaduetoates- Saez JM,DePeretti E,Morera AM, DavidM,Bertrand J. Familial tory manualNew York: ColdSpringHarbor;1989. Sambrook J, Fritsch EF, Maniatis TE. Molecular cloning,alabora- ciency. Gene.2012;499:250-5. gene: a novel type of genetic defect underlying 17β-HSD-3 defi- A, IoannidesM,etal.Duplicationofexons 3-10 oftheHSD17B3 Neocleous V, SismaniC, Shammas C, Efstathiou E, Alexandrou β-hidroxysteroide dehydrogenase 3 and its effect on NADPH 17-β-HSD3 deficiency 539 -

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