Causes, Patterns and Severity of Androgen Excess in 487

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European Journal of Endocrinology -18-0854 University ofSheffield,UK,and Foundation Trust,Birmingham,UK, Birmingham HealthPartners, Women’s andChildren’sHospitalNHSFoundationTrust, 1 Wolfgang Högler Timothy G Barrett Jan Idkowiak post-pubertal children excess in487consecutivelyrecruitedpre-and Causes, patternsandseverityofandrogen acceleration aretypicalpresenting signsinpre-pubertal hair growth,changeinbody odorandtransientgrowth underlying pathologies( of symptomsandisthought tohaveabroadspectrumof Androgen excessinchildhood maypresentwithavariety Introduction be usedtoguidefurtherinvestigations. Conclusions: adrenocortical carcinoma)andinCAHforserumandrostenedione. above thetwo-foldupperlimitofnormalweremostlyobservedinPAforserumDHEAS( had A4excess(86%);testosteroneandDHEASwereincreasedin5033%respectively.Concentrations DHEAS (29%)ortestosterone(25%)increasesinbothA4andtestosterone(25%).CAHpatients(6%)predominantly respectively. PCOSwasdiagnosedin40%ofpost-pubertalsubjects,presentingequallyfrequentwithisolatedexcess diagnosis (61%),characterizedbyDHEASexcessin85%,whileA4andtestosteronewereonlyincreased269% androgen excess(140pre-and59post-pubertal).Prematureadrenarche(PA)wasthemostcommonpre-pubertal Results: Patients withatleastoneincreasedandrogenunderwentphenotypingbyclinicalnotesreview. Methods: Design: androgen excess. we examinedthedifferentialdiagnosticvalueofserumDHEAS,androstenedione(A4)andtestosteroneinchildhood describing itspatternsandseverityarescarce,limitingtheinformationavailableforclinicaldecisionprocesses. Here, Objective: Abstract University Linz,Austria Institute ofMetabolismandSystemsResearch,UniversityBirmingham, https://doi.org/ https://eje.bioscientifica.com Clinical Study Retrospectivereviewofallchildrenundergoingserumandrogenmeasurementatasinglecenterover5 years. In487childrenwithsimultaneousDHEAS,A4andtestosteronemeasurements,weidentified199 SerumA4andtestosteroneweremeasuredbytandemmassspectrometryDHEASimmunoassay. Androgenexcessinchildhoodisacommonpresentationandmaysignifysinisterunderlyingpathology.Data 10.1530/EJE Patternsandseverityofchildhoodandrogenexcessprovide pointerstotheunderlyingdiagnosisandcan 1 , 2 , 3 , Yasir S Elhassan 1 , -18-0854 2 2 , , 3 3 , , Nicholas J Shaw 6 , Ruth E Krone 4 Department ofClinicalBiochemistry,UniversityHospitals BirminghamNHS 1 ). Premature pubic and axillary ). Prematurepubicandaxillary 3 5 Academic UnitofChildHealth,Department ofOncology&Metabolism, 6 Department ofPediatricsandAdolescent Medicine,JohannesKepler J Idkowiakandothers 1 , 3 2 Published by Bioscientifica Ltd. , Pascoe Mannion , 3 , Michael W O’Reilly 1 , 2 , 3 Printed inGreat Britain , Nils Krone 3 © Centre forEndocrinology, DiabetesandMetabolism, 2019Theauthors 2 , 1 3 , , 3 5 2 , Karen Smith , Renuka P Dias Department ofEndocrinologyandDiabetes,Birmingham 1 , syndrome (PCOS)istheleading causeofandrogenexcess underlying diagnosis, whereas adolescent polycystic ovary vast majorityofaffectedpre-pubertal children,PA isthe are presentingfeaturesinpost-pubertal girls( children ( excess Causes ofchildhoodandrogen 3 and Wiebke Arlt 2 4 , Rachel Webster ); menstrualdisturbances with hirsutism 2 , 3 , Melanie Kershaw 1 , 3 Attribution 4.0International License. This workislicensed under a Downloaded fromBioscientifica.com at09/29/202110:18:01AM > 20-fold inthesinglecaseof 4 , Vrinda Saraff (2019) Endocrinology European Journalof [email protected] Email to JIdkowiak should be addressed Correspondence 2 , 3 180 , Jeremy M Kirk 180 :3 , 213–221 Creative Commons

2 , 3 3 213 , ). Inthe –221 1 , 2 via freeaccess , 3 , European Journal of Endocrinology https://eje.bioscientifica.com childhood androgenexcess. the signatures of distinct conditions underlying referralcentertouncoverchildren fromasingletertiary we analyzedalargecohort ofconsecutivelyrecruited approach tochildhoodandrogenexcess.To thisend, we aimedtodeveloptheevidencebaseforarational women presentingwithandrogenexcess.Inthisstudy, clinicians topredictnon-PCOSpathologyinadult a singlecenter( excess inalargesampleofadultwomenrecruited in determining causes, patterns and severity of androgen measurement ofserumDHEAS,A4andtestosterone in conditions. androgen measurementsinchildhoodexcess To date,thereisadearthofdataonLC–MS/MS-based measuring low-abundancesteroidsinchildren( a highlysensitiveanalyticaltool,inparticularwhen (LC–MS/MS) analysis of serum steroids has emerged as 9 DHEAS, inparticularwhenmeasuredisolation( and theandrogenprecursorsandrostenedione(A4) serum concentrations of the active androgen testosterone limit thediagnosticaccuracyofmeasurement which arepronetocross-reactivityandlowsensitivity, children andthewidespreaduseofradioimmunoassays, underlying pathologies. excess consideredpredictiveforbothcommonandrare delineating patternsandseverityofchildhoodandrogen However, there is a paucity of data from larger cohorts and theseverityofbiochemicalandrogenexcess( investigations dependingontheclinicalpresentation presenting symptoms,andclinicianstendtotailorthose required usuallydependsontheseverityandacuityof the clinicalwork-up( and, whereappropriate,imagingstudies,arepartof by hormonalinvestigations,boneageassessment, symptoms andathoroughclinicalexamination,followed including onset,acuity, severityandprogressionof with androgenexcesscanbechallenging.Detailedhistory, extremely rareinchildhood( malignant virilizingadrenaltumors,withthelatterbeing hyperplasia (CAH), precocious puberty or potentially enzyme defects,mostcommonlycongenitaladrenal causes ofandrogenexcesssuchasinbornsteroidogenic the diagnosisofPA andPCOSrequireexclusionofother in pubertal girls after menarche ( ). Liquidchromatography–tandemmassspectrometry Clinical Study We haverecentlyreportedtheutilityofsimultaneous Physiologically lowcirculating androgenlevelsin To reachaconclusivediagnosisinchildpresenting 12 ), generatingusefulguidancefor 1 , 7 ). Theextentofinvestigations 1 , 5 J Idkowiakandothers , 6 1 ). , 2 , 4 ). Importantly, 10 , 11 7 8 ). ). ). , medical history, height,weight,BMI,boneage,ethnicity review, extractinginformationonclinicalpresentation, furtherclinicalphenotypingbycasenote underwent above theTanner stage-specificreference range( at leastoneserumandrogenconcentrationincreased context ofoutpatientclinicappointments.Patientswith were collectedatvariable times duringthedayin measurement ofDHEAS,A4andtestosterone.Samples ( 2013and1stJune2017 BWCH between1stJanuary A4 andDHEASaspartofroutineclinicalcareat had undergonemeasurementsofserumtestosterone, (reference: CARMS-00935).We includedallchildrenwho and Children’s Hospital(BWCH) NHS FoundationTrust data review was obtained from Birmingham Women’s Institutional reviewboardapprovalforretrospective Subjects andclinicalprotocol Patients andmethods generation of graphs. Data were expressed as median GraphPad Prismwasused forstatisticalanalysisand Statistical analysis on theRocheCobasc702analyzer( Roche competitiveelectrochemiluminescenceimmunoassay specific transitions.SerumDHEASwasanalyzedusing the chemical ionizationanddetectedaccordingtocompound- profile, ionized using positive atmospheric pressure separated chromatographicallyusinganisocraticelution following additionofdeuteratedinternalstandardsand Briefly, samplesareanalyzedbyliquid–liquid extraction Triple Quadmassspectrometer asdescribedpreviously( a ShimadzuProminenceXRUPLCcoupledtoSciex6500 on by liquidchromatography–tandemmassspectrometry and testosterone. Serum A4and testosterone were analyzed specific normativereferencerangeasreportedin reference range(forDHEAS)orabovetheTanner stage- concentration increasedabovealocal,age-specific Biochemical androgenexcesswasdefinedasaserum Serum androgenmeasurements were obtainedfromtheBritish1990dataset( H, R EK). Reference data for standardized BMI (BMI SDS) endocrinologist (VS,TGB,NJK,RPD,MW each casewithfinalreviewbyaboard-certifiedpediatric by clinical,biochemicalandradiologicalfindingsin and the underlying cause of androgen excess, as supported excess Causes ofchildhoodandrogen n

= 1525), identifying 487 who underwent simultaneous 1525), identifying487whounderwent Downloaded fromBioscientifica.com at09/29/202110:18:01AM 12 180 ). :3 13 ). 14 n for A4 forA4 =199) 214 12 via freeaccess ). ).

European Journal of Endocrinology PA, prematureadrenarche;PCOS, polycysticovarysyndrome. central precociouspuberty;IPM, isolatedprematuremenarche; congenital adrenalhyperplasia; CD,Cushing’sdisease;cPP, and testosterone.ACC,adrenocortical carcinoma;CAH, underwent simultaneousmeasurementofserumDHEAS,A4 pre-pubertal vspost-pubertalstatusin487childrenwho Flowchart ofthedistributiondiagnosesaccordingto Figure 1 had androgenexcess( account pubertal development, only 199children(40.9%) applying Tanner stage-defined cut-offs, thus takinginto at leastoneincreasedserumandrogen;however, when applying age-definedcut-offs,255children(52.4%)had astheanalysiscohort( were takenforward three androgenshadbeenmeasuredsimultaneouslyand during thestudyperiod.In487children(31.9%),all concentration ofDHEAS,A4ortestosteronemeasured A totalof1525childrenhadatleastoneserum Description ofthecohortanddiagnosticspectrum Results significance wassetat between twonon-evenlydistributedvariables.Statistical rank correlationwasemployedtoassess between two groups (pre- and post-pubertal). Spearman The Mann–Whitney stated. and firstthirdquartile,unlessotherwise Clinical Study U P i. 1 Fig.

< testwasusedforcomparison 0.05. ). Those199childrenwere J Idkowiakandothers Fig. 1 ). When made ( and features were reported orno associated diagnosis was (CD). Inaboutonethirdofcases,miscellaneousdiagnoses adrenocortical carcinoma (ACC) and Cushing’s disease precocious puberty(cPP;2.5%)andonecaseeachof (7.0%), isolatedprematuremenarche (IPM;2.5%),central of androgenexcesswerealsoidentified,includingCAH rareunderlyingcauses In bothsubgroups,rareandvery diagnosis of 21-hydroxylase (CYP21A2) deficiency; 12 had diagnosis of 21-hydroxylase (CYP21A2) deficiency; 12 had androgenic medicationormetformin atpresentation. significant co-morbidities, and theywerenotonanyanti- SDS; IQR:0.91,2.58).NoneofthePCOSsubjectshad median BMIofthePCOSsubjectswas27.1 seven subjects complained about weight gain (29%). The signs of androgen excess (hirsutism and/or acne) and excess. In addition, 63% ( menstrual cycleandbiochemicalfeaturesofandrogen established onthebasisofpresenceanirregular African-Caribbean (8%).ThediagnosisofPCOSwas 75%); threewereCaucasian(12.5%)andtwogirls 15.7). ThemajoritywasofSouth-Asianethnicity( years(IQR:13.1, median ageatpresentationwas15.2 co-morbidities orwereonanyregularmedication. (IQR: 1.16, 2.33). None of the subjects had notable years age advancementinthePA cohortwas1.88 Table 2), althoughacnewasrareinboys.Themedianbone with regardstoclinicalpresentation(Supplementary Caribbean ( as 58.0%Caucasian, 22.5% South Asian and 9% Afro- the generalpopulationinlocalareahasbeenrecorded Asian and12children(14%)ofAfro-Caribbeandescent; were ofCaucasianethnicity, 31children(26%)ofSouth- Forty-onePA children(48%) boysat8.2 years. 7.2 years, girls (79%).GirlswithPA presentedatamedianageof data supplementary was themostcommondiagnosis( diagnosis ofPA ( ethnicity (38.7%)( Caucasian children(44.2%)andofSouthAsian ethnically diverse,withthetwolargestgroupcomprising pre-pubertal group( overall cohortandhigherinthepubertalthan ( ‘Methods’ section. There was a pre-dominance of girls phenotypically further characterized as described in the excess Causes ofchildhoodandrogen al 1 Table The overallmajorityofpre-pubertalchildrenhada All 14 CAH patients had a genetically confirmed All 14CAHpatientshad a geneticallyconfirmed In subjectsdiagnosedwithadolescentPCOS,the The majorityofthe86childrenwithPA were Fig. 1 ). ThemedianBMISDSwasincreasedinthe 15 and Supplementary Table 1, seesectionon Table 1, andSupplementary ). Therewerenonotablegenderdifferences n

= Table 1 86; 61%),whileatpubertalage,PCOS givenattheendofthisarticle). al 1 Table Downloaded fromBioscientifica.com at09/29/202110:18:01AM ). n

= ). Theoverallcohortwas 15) girls also had clinical https://eje.bioscientifica.com n 180 4 4% ( 40%) =24; :3 kg/m i. 1 Fig. 2 n (2.24 215 =18; via freeaccess ).

European Journal of Endocrinology https://eje.bioscientifica.com A4 andtestosterone(25%)( excess (25%) or increased serum concentrations of both with isolatedDHEASexcess (29%),isolatedtestosterone In adolescentPCOS,patients equallyfrequentlypresented in three PAelevated was only observed subjects (3.5%). four (4.7%) subjects. A pattern with all three androgens excess wasrareinPA andonlyfoundinnine(10.5%) of DHEAS and A4 excess. Isolated A4 or testosterone ( presentation inchildrenpresentingwithPA ( Isolated DHEASexcesswasthemostcommonbiochemical underlying diagnosis Patterns ofandrogenexcessaccordingtothe micro-adenoma. pituitary appearance andwasfoundtohaveanACTH-producing gain, easybruising,headachesandtypicalCushingoid years of age with weight boy with CD presented at 13 years withperipheralprecociouspuberty. The of 1.8 one boywithCD.TheACCcasepresentedattheage extremely rare cases, one boy presented with ACC and hair development ofaxillary of androgenexcess(prematurepubarche with earlybreastdevelopmentandadditionalsigns isolated vaginalbleeding.AllgirlswithcPPpresented precocious puberty(cPP).AllIPMcasespresentedwith therapy; thenon-classiccaseswerenotonmedication. CAH. AllclassicCAHcaseswereonsteroidreplacement the classicsalt-wastingformandtwosubjectshadnon-classic mixed 4.4%andother2.0%. *Ethnicity distributionpatternintheBirminghamareais:Caucasian58.0%,Asian26.6%(SouthAsians22.5%,other4.08%),Afro-Caribbean 9.0%, United KingdomCensus2011,OfficeforNationalStatistics( Unknown Other Mixed background Afro-Caribbean South Asian Caucasian Ethnicity* (%) BMI SDS(median(Q1,Q3)) BMI (kg/m Boys Girls Gender (%) Age (years;median(Q1,Q3)) Patients with the referencerangeforatleastoneofthreemeasuredandrogens(DHEAS,androstenedioneandtestosterone). Table 1 Fig. 2A Clinical Study We identifiedfivegirlswithIPMandcentral ). ElevenPA subjects(12.8%)hadacombination Baseline demographicsof199childrenwithbiochemicalandrogenexcessasdefinedbyserumconcentrationsabove 2 ; median(Q1,Q3)) ≥ 1 of3androgensincreased Fig. 2B J Idkowiakandothers n ). ; acne =3; n 58; 67.4%) =58; n 15 ; early =4; n ). 13 (6.5) 1 (0.5) 3 (1.5) 16 (8.0) 76 (38.7) 91 (44.2) 1.35 (0.2,2.6) 19.5 (16.4,25.1) 58 (29.2) 141 (70.8) 8.3 (6.8,13.3) 199 Total ) In =2). was foundinaminority of childrenwithPA (10%), ( found inanumberofsubjects withPA, PCOSand CAH severe ( than girls( CD hadsevereA4excess.InPA, A4washigherinboys children withPA (24%)andintheACCcase.Theboywith in adolescentPCOS (42%), in some ULN) was observed 3).Mild-to-moderateA4excess (one-totwo-fold Table in classicCAHpatients( normal DHEASlevels( to 28-foldULN.ThemajorityofchildrenwithCAHhad single ACCcasepresentedwithserumDHEASincreased The Table 3). Fig.1andSupplementary (Supplementary Table 3). PA girlshadhigherDHEASthanboys( did not exceed eight-fold ULN ( one totwo-foldabovetheupperlimitofnormal(ULN)and In childrenwithPA, serumDHEASwasmostlyincreased Severity ofandrogenexcess the CDcasehadisolatedA4excess. In the ACC case, both DHEAS and A4 were increased, and excess andincreasesinallthreeandrogensrespectively. pubertal CAHpatientpresentedwithisolatedtestosterone inCAHchildren,andonlyonepre- was neverobserved in 50and33%respectively( A4 excess(86%);testosteroneandDHEASwereincreased excess Causes ofchildhoodandrogen Fig. 3C Both mild-to-moderate(one- totwo-foldULN)and A4 excessabovetwo-foldULNwastypicallyobserved Children with CAH predominantly presented with > and Supplementary Table 3). andSupplementary Testosterone excess 11 (7.2) 0 2 (1.5) 13 (9.4) 50 (36.9) 64 (44.2) 1.26 ( 17.9 (15.9,22.0) 51 (36.4) 89 (63.6) 7.4 (4.6,8.5) 140 (70.3%) Pre-pubertal two-fold ULN)excessofserum testosteronewas P .08 (upeetr Fig. 1). (Supplementary =0.0008) − 0.1, 2.5) Fig. 3A Downloaded fromBioscientifica.com at09/29/202110:18:01AM i. 3B Fig. and Supplementary Table 3). andSupplementary Fig. 3A i. 2C Fig. and Supplementary andSupplementary 3 (4.9) 1 (1.6) 1 (1.6) 3 (4.9) 26 (44.1) 27 (44.2) 1.88 (0.6,2.7) 26.8 (19.8,31.0) 7 (11.9) 52 (88.1) 14.9 (13.4,15.6) 59 (29.7%) Pubertal 180 and Supplementary and Supplementary ). IsolatedDHEAS :3 P =0.036) 216 via freeaccess European Journal of Endocrinology bars post-pubertalsubjects. hyperplasia. Whitebarsrepresentpre-pubertalsubjects,black syndrome and(C)childrenwithcongenitaladrenal with prematureadrenarche,(B)girlspolycysticovary Distribution ofserumandrogenexcesspatternsin(A)children Figure 2 Clinical Study J Idkowiakandothers excess patternandseverityinthepre-post-pubertal enabled ustoprovideseparateanalysesofandrogen children withbiochemicallyconfirmedandrogenexcess, of 5.5million.Thesizeourcohort,comprising199 pediatricreferralcenter,tertiary coveringapopulation consecutively recruitedchildrenandadolescentsinasingle A4 aswelltheactiveandrogentestosteronein487 concentrations oftheandrogenprecursorsDHEASand Here, wehavesimultaneouslymeasuredtheserum Discussion in oneadolescentgirl. testosterone excess,whichwassevere(five-foldelevation) only ( excess wasfoundin63%ofcases,butsevereone 1).InPCOS,testosterone with PA Fig. (Supplementary serum testosteronedidnotdifferbetweenboysandgirls but twoboyshadseveretestosteroneexcess;overall, concentrations insubjectswith PA ( Two studiesreportedimmunoassay-based androgen details onandrogenmetabolismincludingseveritylevels. reviews), however, generallywithoutprovidingfull consequences inPA (( backgrounds, butmainlyfocusingonmetabolic 10–100 studysubjectsofvariousethnical–geographical control studies, in well described cohorts consisting of yearsinseveralcase- has beenstudiedoverthepast30 excess conditions,mainlyPA andadolescentPCOS.PA pre-selected samplesofchildrenwithdistinctandrogen the overallcatchmentarea. of our center to areas with higher ethnic diversity within PCOS inSouthAsiansubjects( group. Thismaypartiallyreflectthehigherincidenceof representation of South-Asian ethnicity in the PCOS Caribbean ethnicitiesinPA childrenandparticularover- was someover-representationofSouthAsianandAfrican- comparison tothelocalbackgroundpopulation,there diverse;in The studypopulationwasethnicallyvery rarediagnoses. study populationforrareandvery spectrum of underlyingconditions.Thisenriched our gonadal pathologies,increasingthediverseandcomplex but alsopatientswithsuspicionofcomplexadrenaland presenting withclinicalfeaturesofandrogenexcess, age subgroups.Ourstudycohortincludedchildren excess Causes ofchildhoodandrogen Previous studieshaveassessedserumandrogensin i. 3C Fig. ). InclassicCAH,sixsubjects(50%)had 1 Downloaded fromBioscientifica.com at09/29/202110:18:01AM , 2 , 17 16 https://eje.bioscientifica.com , ) aswelltheproximity 18 ) forcomprehensive 180 19 , :3 20 ). Virdis 217 et al via freeaccess . European Journal of Endocrinology https://eje.bioscientifica.com ovary syndrome. menarche); PA,prematureadrenarche; PCOS,polycystic central precociouspuberty;open circles:isolatedpremature Cushing’s disease;DoP,disorders ofpuberty(closedcircles: (closed circles:classicCAH;open circles:non-classicCAH);CD, adrenocortical carcinoma; CAH, congenital adrenal hyperplasia from 2-foldULNisindicatedbyablackdottedline.ACC, line. Anarbitrarydefinedcut-offforsevereandrogenexcess indicate androgenexcess,indicatedbytheblackinterrupted above upperlimitofnormal(ULN)’;levels‘1’therefore Androgen excesslevelsarerepresentedas‘foldincrease for eachdiagnosisaredenotedbyasolidblackorwhiteline. androstenedione and(C)serumtestosterone.Medianvalues androgen measuredfor:(A)serumDHEAS,(B) Severity ofandrogenexcessaccordingtodiagnosisandserum Figure 3 Clinical Study J Idkowiakandothers

detected inthemajorityofchildrenwithPA whileA4 even rarercauses. presenting withandrogenexcesssuchasCAHorother neither howthesedifferentiatePA fromotherconditions excess inPA hasnotbeenanalyzedindetailpreviously, ( increased whenreferringtoage-specificreferenceranges serum DHEASappropriateforTanner pubertalstagebut key featureofPA ( increase indownstreamandrogensisrecognizedasa above theage-specificreferencerangeandamarginal were upto5-foldelevatedin18PA subjectsstudied( DHEAS levels, but found that unconjugated DHEA and A4 most subjectsstudied( controls, butnormalA4andtestosteroneexcessonlyin up to9-foldabovetheupperlimitofage-matched reported elevated DHEAS levels in the majority of subjects with similarpotencytotestosterone( been showntobindandactivatetheandrogenreceptor converted to11-ketotestosterone(11KT),whichhas 11-hydroxy-androstenedione, whichcanbefurther (CYP11B1) enzymeefficientlyconvertsA4to The adrenalP450cytochrome11 excess inconditionslikePCOSandCAH( 11-oxygenated androgensasamajorsource ofandrogen action. Ourgroupandothershaverecentlyhighlighted could occur within the target tissues of androgen conversion ofde-sulfatedDHEAtopotentandrogens to theandrogenreceptor, suggestingthatdownstream action. DHEAS isan inactive metabolitewithnoaffinity subjects, despiteclinicalevidenceofincreasedandrogen and testosteronewereincreasedonlyinaminorityof spectrometry (LC–MS/MS) forthe measurement of A4 spectrometry has employedmoresensitive andspecifictandemmass concentrations usuallyfound inchildren.Ourstudy to cross-reactivityandless sensitive tolowercirculating ( children, in particular the initial reports from the 1970s the pastinstudiesassessingandrogenmetabolism in in ourcohort. childhood androgenexcessand,thus,wasnot measured yet formpartofroutineandrogenassessment in measurement of11-oxygenatedandrogensdoesnot via increased11-oxygenatedandrogens.However, thatandrogeniceffectsinPAtheory maybemediated prominently inchildrenwithPA ( recently been shown to featurefact, 11KT has very excess Causes ofchildhoodandrogen 22 31 , , In ourcohort,increasedserumDHEASwas Adrenal androgenexcesswithelevatedserumDHEAS Radioimmunoassays (RIAs) were employed in 32 23 ), whicharefrequentlyreferenced. RIAsareprone ). Ofnote,thepatternandseverityofandrogen 2 19 , Downloaded fromBioscientifica.com at09/29/202110:18:01AM 21 ). Voutilainen ); otherssuggestedincreased 30 180 et al ), supportingthe :3 24 24 . didnotreport β , -hydroxylase , 28 25 , , 26 29 218 , ). In 20 27 via freeaccess ). ). ).

European Journal of Endocrinology onset ofpubertywithashorter peakheightvelocity( shown thathigheradrenalandrogens arelinkedtoanearlier pre-existing) exaggeratedadrenarche. Indeedithas been mild DHEASexcess,which could reflectconcomitant(or of serumandrogens.Inourstudy, allfivegirlswithIPMhad additional (early)pubarche, whichpromptedtheassessment with cPP(but none of the girls with IPM) in ourcohort had reported inmorethan60%ofchildrenwithcPP( are rarelypartofthespectruminIPM( hair development puberty (cPP)orIPM.Pubicaxillary circulating androgensingirlswithcentralprecocious from otherdisordersassociatedwithandrogenexcess. interpreting serum androgen profiles todifferentiate CAH characteristic profile,whichishelpfulfortheclinician in inourCAHstudysampleformavery signatures observed diagnosed CAHpatients.However, theserumandrogen excess willbedistinctfromandrogeninnewly therapy and hence severity and pattern of androgen CAH inourcohortwereonhydrocortisonereplacement sensitivity andspecificity( shown todistinguishPA fromnon-classicCAHwithhigh serum 17OHPthresholdof2 work-up of childhood androgen excess ( deficiency, andshouldbeincludedinthediagnostic of themostcommonformCAH,21-hydroxylase would bethekeybiochemicaldiscriminatortodetect and testosteroneexcess.Certainly, 17OHPelevation Children withCAHpresentedpredominantlyA4 to discriminatenon-PA andnon-PCOSpathology. and severityofandrogenlevelsmayhelptheclinician childhood androgen excess conditions, the patterns when referringtoreferencedata. is probablymostappropriatefordailyclinicalpractice reference valuesobtainedfromaleancohort( DHEAS wasthemostcommonfinding. We usedstandard menopausal PCOSwomen( contrast tothisstudy, butalsoourpreviousreportonpre- DHEAS comparedtoBMI-matchedcontrols.Thisisin reported elevatedA4andtestosteronelevels,butnormal girls with adolescent PCOS ( measurements ofandrogenswerereportedin40obese assessment ofchildhoodandrogenexcess. findings can provide guidance for risk stratification in the with moreresultsthanrequestedinthefirstplace.Our increasing frequency, whichconfrontstheclinicianoften steroid panels with now using mass spectrometry-based laboratories are and testosterone. Clinical biochemistry Clinical Study Previous work has provided limited information on Previous workhasprovidedlimitedinformationon In ordertobiochemicallycharacterizecommon Only recently, LC–MS/MS-basedlongitudinal 34 ). Allthepatientswithclassic 33 12 ng/mL (6 ). Interestingly, that study ), whereelevatedserum J Idkowiakandothers 35 nmol/L) hasbeen ), but have been ), buthavebeen 1 , 7 36 14 ). A basal ). All girls ). Allgirls ), which 37 ). ). androgen concentrationsatpresentation,however, are abnormality in childhood ACC ( androgen excessisthemostfrequentlypresentingsteroid years), the US (41 cases identified over a period of 60 on arecentlargercaseseriesofchildrenwithACCfrom although the family was of South Asian origin. Based patient also carried the Brazilian TP53 founder mutation, 487 childrenovera5-yearstudyperiod.Interestingly, our in our study population with a single case diagnosed in the prevalent duetoadistinctfoundermutation(p.R337H)of certain geographicalareaslikeBrazilwhereACCismore lining, ultimatelyresultinginmenarche. of estrogens, enhancing the build-up of the endometrial androgens couldexposetheendometriumtohigherlevels However, onemightspeculatethataromatizationofexcess it isconsideredtobeabenign,self-limitingcondition( The underlyingetiologyofIPMisnotwellunderstood,and hs ok a fne b te eloe rs (netgtr Award (Investigator Trust Wellcome support from theNIHRBiomedical UK ClinicalLecturerandWAreceives the by (NIHR) Research Health of Institute National a is I J A). funded W to 209492/Z/17/Z was work This Funding be could that interest of conflict perceived asprejudicingtheimpartialityofthisstudy. no is there that declare authors The Declaration ofinterest EJE-18-0854 This islinkedtotheonline version ofthepaperat Supplementary data exclude sinisterunderlyingpathology. prompt thecliniciantoperformfurtherinvestigations to PCOS; serumDHEASincreasedabove8-foldULNshould characteristic for PA and frequently found in adolescent typically features A4 excess. In contrast, DHEAS excess is A4 andtestosterone.DHEASexcessisrareinCAH,which the utilityofcombinedmeasurementsserumDHEAS, frequency ofchildhoodandrogenexcessconditionsand findings provideuniqueinsightsintothevarietyand cohort of children of pre- and post-pubertal age. Our of patternandseverityandrogenexcessinalarge exclude ACC-relatedandrogenexcess. ULN shouldprompturgentfurtherinvestigationsto certainly indicatethatsevereDHEASexcessbeyond8-fold study and what is known from the literature, the findings assay methodologies. Based on our of cases and varying to therarityofdisease,complicatedbyhistoricnature not widelyreportedinchildhoodACC,presumablydue excess Causes ofchildhoodandrogen TP53 ACC isanextremelyrareentityinchildren,apartfrom In conclusion,wehaveundertakenadetailedanalysis gene( . 38 ). ThegeneralrarityofACCisalsoreflected Downloaded fromBioscientifica.com at09/29/202110:18:01AM https://eje.bioscientifica.com 39 180 ). 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