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In Children and Adults with Primary Adrenal Failure: Ten Years’ Experience

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In Children and Adults with Primary Adrenal Failure: Ten Years’ Experience 0021-972X/06/$15.00/0 The Journal of Clinical Endocrinology & Metabolism 91(8):3048–3054 Printed in U.S.A. Copyright © 2006 by The Endocrine Society doi: 10.1210/jc.2006-0603 Analysis of DAX1 (NR0B1) and Steroidogenic Factor-1 (NR5A1) in Children and Adults with Primary Adrenal Failure: Ten Years’ Experience Lin Lin, Wen-Xia Gu, Gokhan Ozisik, Wing S. To, Catherine J. Owen, J. Larry Jameson, and John C. Achermann UCL Institute of Child Health and Department of Medicine (L.L., W.S.T., J.C.A.), University College London, London WC1N 1EH, United Kingdom; Department of Medicine (W.-X.G., J.L.J.), Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois 60611; Division of Endocrinology and Metabolism (G.O.), Gulhane Askeri Tip Akademisi Medical School, Haydarpasa Hospital, Istanbul 34670, Turkey; and Institute of Human Genetics (C.J.O.), School of Clinical Medical Sciences, University of Newcastle, Newcastle upon Tyne NE1 3BZ, United Kingdom Context: Primary adrenal failure is a life-threatening condition that viduals presented in adulthood with Addison’s disease of unknown can be caused by a range of etiologies, including autoimmune, met- etiology. abolic, and developmental disorders. The nuclear receptors DAX1 (NR0B1) and steroidogenic factor-1 (SF1/Ad4BP, NR5A1) play an Methods: Mutational analysis of DAX1 (NR0B1) (including exon important role in adrenal development and function, and mutations 2␣/1A) and SF1 (NR5A1) was done by direct sequencing. in these transcription factors have been found in patients with ad- renal hypoplasia. Results: DAX1 mutations were found in 58% (37 of 64) of 46,XY phe- notypic boys referred with adrenal hypoplasia and in all boys (eight of Objective: Our objective was to investigate the prevalence of DAX1 eight) with hypogonadotropic hypogonadism and a family history sug- and SF1 mutations in children and adults with primary adrenal gestive of adrenal failure in males. SF1 mutations causing adrenal fail- failure of unknown etiology (i.e. not caused by congenital adrenal ure were found in only two patients with 46,XY gonadal dysgenesis. No hyperplasia, adrenoleukodystrophy, or autoimmune disease). DAX1 or SF1 mutations were identified in the adult-onset group. Patients: One hundred seventeen patients were included. Eighty- Conclusions: DAX1 mutations are a relatively frequent cause of eight individuals presented in infancy or childhood with adrenal adrenal failure in this group of boys. SF1 mutations causing adrenal hypoplasia or primary adrenal failure of unknown etiology (n ϭ 64 failure in humans are rare and are more likely to be associated with 46,XY phenotypic males; n ϭ 17 46,XY gonadal dysgenesis/im- significant underandrogenization and gonadal dysfunction in 46,XY paired androgenization; n ϭ 7 46,XX females). Twenty-nine indi- individuals. (J Clin Endocrinol Metab 91: 3048–3054, 2006) RIMARY ADRENAL FAILURE is a potentially life- Deletions or mutations of DAX1 (NR0B1, Xp21) [Men- P threatening disorder that can present with a salt- delian Inheritance in Man (MIM) no. 300473] cause the losing crisis or profound hypoglycemia in infancy or child- X-linked form of primary adrenal hypoplasia (AHC) (MIM hood and requires urgent resuscitation and appropriate no. 300200) (4, 5). Boys with this condition usually present steroid replacement. Determining the exact cause of this with salt-losing primary adrenal failure in early infancy or condition can be challenging once the child has started in childhood (6). Absent or arrested puberty occurs in treatment, but defining a precise etiology has important adolescence because of hypogonadotropic hypogonadism implications for long-term management, for identifying (HH), and intrinsic abnormalities in spermatogenesis con- associated features, and for appropriate counseling re- tribute to impaired fertility (4–10). Although more than garding inheritance and the risks of other family members 100 individuals or kindred with X-linked AHC have been being affected (1, 2). reported, the prevalence of DAX1 mutations in individuals Two related transcription factors that have emerged as key with different adrenal phenotypes or associated features is regulators of adrenal development are the nuclear receptors not clear (11–18). DAX1 [dosage-sensitive sex reversal, adrenal hypoplasia con- Recently, a late-onset form of X-linked AHC has been genita (AHC), critical region on the X chromosome, gene-1, described in several individuals who first presented with NR0B1/AHC] and steroidogenic factor-1 (SF1, NR5A1, also adrenal failure and partial hypogonadism in adulthood (19– known as Ad4BP) (3). 21). These reports raise the possibility that milder or even adrenal-only forms of AHC resulting from DAX1 mutations could exist. Furthermore, as gonadal (testicular) dysgenesis First Published Online May 9, 2006 Abbreviations: AHC, Adrenal hypoplasia congenita; HH, hypogo- has now been reported in Dax1 (Ahch) deleted mice when nadotropic hypogonadism; SF1, steroidogenic factor-1. bred onto certain genetic backgrounds (22), we hypothesize JCEM is published monthly by The Endocrine Society (http://www. that DAX1 mutations might be identified in a subset of 46,XY endo-society.org), the foremost professional society serving the en- individuals with primary adrenal failure and impaired tes- docrine community. ticular development. 3048 Lin et al. • DAX1 and SF1 in Adrenal Failure J Clin Endocrinol Metab, August 2006, 91(8):3048–3054 3049 The related nuclear receptor SF1 (NR5A1) (9q33) regulates hood or a personal history of abnormal puberty/HH (Tables 1 and 2). transcription of many genes involved in adrenal and gonadal Other clinical features (e.g. skeletal abnormalities or intrauterine growth development, steroidogenesis, and reproduction (23, 24). retardation) were present in 12 patients. Of these, six individuals had potential variants on the IMAGe syndrome (intrauterine growth retar- Targeted deletion of Sf1 in the mouse causes adrenal and dation, metaphyseal dysplasia, adrenal hypoplasia, genitourinary ab- gonadal agenesis, retained Mu¨ llerian structures, and im- normalities), but no children had features of the Antley-Bixler syndrome paired androgenization in males, abnormal gonadotropin (37). Transient or borderline adrenal failure was present in five cases release, and late-onset obesity (25, 26). (Table 2). This phenomenon was defined as a cortisol response to syn- acthen less than 15 ␮g/dl (420 nmol/liter) when investigated for hy- Human mutations in SF1 have been described in three poglycemia in the neonatal period and requiring steroid replacement for patients with primary adrenal failure to date (MIM no. several months or years, which was eventually weaned and stopped 184757). Two individuals with a 46,XY genotype, female (Table 2). These boys were included because transient forms of AHC phenotype, and Mu¨ llerian structures harbor missense mu- have been described in patients who present in early infancy, improve tations that affect DNA binding (27–29), whereas a 46,XX girl in childhood, but develop significant adrenal failure in adolescence (38). In addition to the 46,XY phenotypic males, we considered a cohort of with a SF1 mutation has primary adrenal failure and appar- underandrogenized 46,XY patients (ambiguous genitalia or female phe- ently normal ovarian development (30). In addition, it is now notype) with primary adrenal failure (n ϭ 17), with (n ϭ 4) or without emerging that heterozygous nonsense or frameshift muta- (n ϭ 13) Mu¨ llerian structures, as well as a small group of 46,XX girls with ϭ tions associated with haploinsufficiency of SF1 can cause isolated primary adrenal failure of unknown etiology (n 7) (Table 1). Three of the underandrogenized 46,XY children had low birth weight or 46,XY gonadal dysgenesis in patients with normal adrenal mild dysmorphic features. Two of these 46,XX girls had evidence of low function (31–33). Thus, it is possible that a range of different birth weight and short stature/skeletal abnormalities. endocrine phenotypes could be associated with mutations in The adult-onset group (n ϭ 29) consisted of 46,XY males (n ϭ 14) and different domains of SF1. 46,XX females (n ϭ 15) who presented with primary adrenal failure of Here, we report our experience over the past 10 yr of unknown etiology after puberty (median age, 33 yr; range, 15–70 yr) (Table 1). These patients were thought initially to have autoimmune analyzing DAX1 and SF1 in 117 children and adults with Addison’s disease but were autoantibody negative and had no other primary adrenal failure that is not caused by disorders that autoimmune endocrinopathies or infective causes and no remarkable are commonly recognized (i.e. congenital adrenal hyperpla- family history. One male had partial HH, and all patients were receiving sia, adrenoleukodystrophy, or autoimmune disease). mineralocorticoid replacement. Subjects and Methods Mutational analysis of DAX1 (NR0B1) and SF1 (NR5A1) Subjects After institutional board approval and with informed consent, genomic DNA was extracted from peripheral blood lymphocytes and A total of 117 individuals with primary adrenal failure were consid- the entire coding regions and splice sites of SF1 (NR5A1, exons 2–7, 10 ered for this study (Table 1). This cohort represents referrals to our primer pairs) and DAX1 (NR0B1, exons 1–2, six primer pairs) were centers over a 10-yr period. For the purposes of this analysis, we have amplified by PCR using variations on conditions reported previously. included 15
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