Copyright© AE&M all rights reserved. Débora R. Bertola Berenice B. Mendonca hypoplasia inaPORpatient. hormone replacementtherapies. We alsodescribedalatesurgicalapproach forthecorrection offacial large ovarian cystsandlateonsetadrenalinsufficiency duringfollow-up, bothofeach regressedafter bone malformation,whowas diagnosedafter duetosexualinfantilism.Shedeveloped 13 years long-term evolution. We described a 46,XX patient with mild atypical genitalia associated with severe asymptomatic newbornsdiagnosedduringneonatalscreeningtest.Little isknownaboutthePORD glucocorticoid deficiency, malformationssimilarto withorwithoutskeletal Antley-Bixler syndrometo of sexual differentiation,result in widephenotypicvariabilityranging from 46,XXor46,XYdisorders enzymatic activity. that POR mutations causevariableimpairmentsin steroidogenic enzyme activities (including 21-hydroxylase, 17α-hydroxylase 17,20 lyaseandaromatase),which isfundamentalfortheir nicotinamide adenine dinucleotide phosphate (NADPH) to all microsomal cytochrome P450 type II by P450 oxidoreductase deficiency(PORD)isavariantofcongenitaladrenal hyperplasia thatiscaused SUMMARY 500 C INTRODUCTION D.Beatriz S. F. Bonamichi to P450-oxidoreductase deficiency congenital adrenal hyperplasiadue follow-up ofafemalewith Long-term from atypical genitalia in both sexes, adrenocortical atypical genitaliainbothsexes,adrenocortical from ofclinicalmanifestationsranging phenotypic spectrum awide produces variability inenzymaticimpairments in a same patient (3,4). This compromised be differently However, (aromatase). and P450aro eachenzymemay lyase),P450c21(21-hydroxylase) hydroxylase/17,20 P450c17(17α enzymes involvedinsteroidogenesis: ofthekey andcombinedimpairment causes partial described in2004(1,2). P450enzymestypeII,wasfirst to allthemicrosomal donor (POR),whichisanelectron oxidoreductase P450 mutations inthegeneencodingprotein enzyme. A new CAH variant due to steroidogenic mutations inasinglegene,whichencodes from MostCAHresult thesynthesisofcortisol. affect case report POR genemutations. electronsfrom The PORgeneencodesaflavor proteinthattransfers P450 oxidoreductase deficiency (PORD) deficiency(PORD) P450 oxidoreductase a group of autosomal recessive diseasesthat ofautosomalrecessive a group hyperplasia(CAH)comprises ongenital adrenal 3,4 , Chong A. Kim Arch EndocrinolMetab. 2016;60(5):500-4 2 , Tania A. S. S. Bachega 1 , L. Stella M. Santiago 3 ,Nivaldo Alonso 2 , 2 , G. Larissa Gomes

- 5 ,

most accepted hypothesis is the androgen production production most accepted hypothesis is the androgen by theclassicalpathway.precursors Consequently, the thesynthesisof fetalandrogenic which compromises However, the17,20-lyaseactivityisoftenimpaired, toestrogens. precursors conversion offetalandrogen placental P450c19activity, the whichjeopardizes justify this virilization in females. First, decreased two hypotheses to are There hyperandrogenism. genitalia virilizationwithoutpostnatal external prenatal Incontrast,girlsoftenhave synthesis ofandrogens. 17,20 lyaseactivity, thetesticular whichdecreases of genitalia virilization due to impairment external peculiar inPORD.Boysusuallyhaveincomplete andpolycysticovarianmorphology(1). amenorrhea in46,XXpatientswithprimary has alsobeenreported (1,4-8).Alateonsetform of asymptomaticnewborns test intheneonatalscreening abnormalities laboratory to associated or not tobonemalformations, insufficiency The ambiguousgenitaliainbothsexesisquite 2 Arch Metab. Endocrinol 2016;60/5 Accepted on:Jun/6/2016 Received on:Jan/22/2016 [email protected] –SãoPaulo,05403-900 SP, Brasil 2º andar, bloco6 Aguiar, 155, Av. DrEnéasdeCarvalho Larissa G.Gomes Correspondence to: (HC-FMUSP), SãoPaulo, SP, Brasil da Universidade deSãoPaulo Clínicas, Faculdade deMedicina de Cirurgia das Plástica,Hospital Genoma HumanoeCélulas HC-FMUSP), SãoPaulo, SP, Brasil Universidade deSãoPaulo (ICr- Faculdade deMedicinada dasClínicas, da Criança,Hospital São Paulo, SP, Brasil de SãoPaulo (HC-FMUSP), de MedicinadaUniversidade dasClínicas,FaculdadeHospital de EndocrinologiaeMetabologia, Unidade de Adrenal, Disciplina Genética Molecular–LIM/42, (ISCMSP), SãoPaulo, SP, Brasil Misericórdia deSãoPaulo Casade Irmandade daSanta deMedicina, Departamento 5 (USP), SãoPaulo, SP, Brasil Universidade deSãoPaulo -Tronco, Instituto deBiociências, 4 3 2 1 DOI: 10.1590/2359-3997000000213 Departamento deCirurgia,Departamento Divisão Centro dePesquisa sobreo Unidade deGenética,Instituto Laboratório deHormôniose Unidade deEndocrinologia, - Arch Metab. Endocrinol 2016;60/5 11.5 years old. She was at approximately and thelarche neonatal dehydration. of noreports were adaptation passedwell,and there inthefaceand upper limbs.Postnatal abnormalities only the presence at birth, not observed 2700g andheightof47cm),atypicalgenitaliawas signsinhersecondpregnancy.hyperandrogenic during firstpregnancy. Themotherdevelopedsimilar Morphological ultrasonographywasnotperformed the eighthmonthofanunknownetiologicalfactor. her firstpregnancy, tofetaldeath in whichprogressed during voicetimbre development ofacneandincreased the Brazil.Themotherreported in Northeastern Bahia, natives of Juazeiro, consanguineous parents, to The patientwasthesecondchildborn CASE REPORT of midfacehypoplasia. andthesurgical management duringpuberty treatment tomedical approaches highlighting thedifferent bone malformations, genitalia associatedwithsevere onecaseofa46,XXpatientwithmildatypical report onlyidentifiedduringdevelopment sometimes theywere invariablecombinationsandintensities, observed are described(12).Theseskeletalmalformations steels were or radio-ulnarsynostosis,camptodactyly, andfemoral craniosynostosis, midfacehypoplasia,radiohumeraland/ metabolism (CYP26) (11).Bonedefectssuchas ( synthesis pathway, 14a-demethylase suchaslanosterol ofenzymesinvolved inthesterol of theimpairment because characteristics ofAntley-Bixlersyndrome that are (10). tospontaneousrupture ovarian cystsprone developmentandlarge incomplete pubertal were hypogonadism. Infemales,there hypergonadotropic evolutionofsevenpatients whodeveloped the long-term thatdescribes intheliterature isonly onereport there P450c17 activityandP450c19inwomen.However, of follow upbecauseofthecommitmentimpairments during ofsexsteroids a collapseintheproduction (DHT)(2,6,9). dihydrotestosterone to 17OH-progesterone SRD5A1 andAKR1C,convert “backdoor pathway”,inwhichenzymes,suchas by ), and enzymes involved in retinoic acid acid CYP51A1), andenzymesinvolvedinretinoic The patient developed pubarche at11yearsold The patientdevelopedpubarche of (birthweight toterm The patientwasborn Due torarityofthediseaseanddatascarcity, we Patients withPORDmayalsoexhibitbonedefects It isexpectedthatpatientsofbothsexeswilldevelop an alternative pathwayduringfetal life,calledthe an alternative of severe bone of severe arachnodactylyin hands, shortening ofthe4 arachnodactylyin hands,shortening andlimitedupperlimbmotion, elbow restriction severe ears, pear-shaped nose,dysplasticandprotruding nasal bridge, depressed midface hypoplasia,proptosis, fusion of major labia (Prader II). Microbrachycephaly, hair Tanner 2 cm,anda posterior III,clitoromegaly Tanner of 112 x 78 mmHg, breasts pressure II, pubic of 79cm(SD0),weight29.6kg-1,63),blood (SD 0),target heightwas160.8cm,sitting and bonemalformations. amenorrhea 13 years old for investigation of primary whenshewasapproximately toourdepartment referred age (BA) of 10 years old, shortening ofthe4 age (BA)of10yearsold,shortening with radio-humeralsynostosis,carpalbonefusion, cognition andschoolperformance. RV: reference valuesforthefemalefollicularphase. radioimmunoassay (17OHP)andandrostenedione, cortisolbychemiluminescence. Progesterone andtestosteroneweremeasured by fluoroimmunoassay, 17OH-progesteroneby Table 1. Basaland ACTH-stimulated adrenalsteroidlevels consistent with hypergonadotropic hypogonadism. consistent withhypergonadotropic value>22pg/mL,fluorimmunoassay), (pubertal immunofluorimetric assay)andestradiolwas17pg/mL rangeforTannerUI/L (normal IIuntil1,2UI/L, 3.9 UI/L,immunofluorimetricassay),LHwas19,2 rangeTannerFSH was12,7UI/L(normal IIuntil elevated (Table 1). Basal moderately and very were andprogesterone 17OH-progesterone The precursors lowatbaselineandinthe ACTHtest. DHEA) were and testosterone levels(androstenedione, androgen intheACTH-stimulationtest.Serum observed was response butanimpaired normal, levels were stimulation test(250mcgi.v.). cortisol Basalserum levelsatbaselineandafteranACTH- progesterone 17OHPlevelsandmarkedlyincreased serum increased and abdominalultrasoundwithmildrightpyelectasia. echocardiogram CT scanshowedpansynostosis;normal metatarsus, scoliosis, exostosis in clavicles; 3D cranial 5 Cortisol (µg/dL) DHEA (ng/mL) Androstenedione (ng/mL) 17OHP (ng/mL) Progesterone (ng/mL) Time (min) Testosterone (ng/dL) th toes were also observed. The patient had normal The patient had normal also observed. toes were Physical examination revealed aheightof154cm Physical examinationrevealed Complementary exams revealed: skeletal survey skeletal survey exams revealed: Complementary The initial hormonal investigation found moderately The initial hormonal Management ofP450oxidoreductase deficiency 6,7-22,6 < 12-48 0,4-1,1 0-2,2 0-1,1 RV < 12 20.7 25.2 12.6 -60 < 1 1.0 16.5 9.7 0.7 8.4 1 0 th and5 th 32.4 71.1 11.6 1.1 0.8 60 and 501 th

Copyright© AE&M all rights reserved. Copyright© AE&M all rights reserved. 0.634 g/cm²(Z-2.8),femoralneckof0.617 totalfemur mineral density(BMD)wasalsoobserved: therapy. replacement cycles underestrogenic Lowbone menstrual regular follow-up, andsheispresenting duringthelastyearof developmentimproved Breast (medications availablewithourPublicHealthSystem). with estradiolvalerate(2mg)andlevonorgestrel with combined treatment replaced were estrogens ofovariancysts.Theconjugatedequine regression acomplete old. Thenextultrasoundimagerevealed whenshewas14.5years occurred 14, andmenarche atage duetotheabsenceofmenarche introduced (0.3mg/day)were 5.3 mL.Conjugatedestrogens volume was17.5mL,andleftovarian measuring 2.8cmintherightovary. Fullrightovarian and bilateralpolycysticovaries,withthelargest cyst changes inthePORgenecopynumber. Amplification-ligands(MLPA)Probe didnotidentify Multiplex Dependent in her parents. heterozygosis was identifiedinahomozygousstatethepatientand sequencing.Thep.A287Pmutation anddirect regions and submittedtoPCRamplificationofPOR 502 deficiencysince its patients with P450-oxidoreductase in descriptionsof increase hasbeen agrowing There DISCUSSION 0.1 mg/day). therapy(dexamethasonesolution of glucocorticoid with the reintroduction that improved drowsiness fatigueand chronic withdrawal, shedevelopedsevere for5days.Afterthe glucocorticoid first facialsurgery doseateachprocedure. glucocorticoid thestress 2). Thepatientreceived (Figure harmony wasrhinoplastytoadjustthefacial for refinements Thelastprocedure area. offrontal the projection moldedimplanttoimprove used, followedbyacrylic tissueexpanderwas Inasecondprocedure Martin). KLS devicefrom with theRED(rigidexternal class IIImalocclusion;thiswasagradualadvancement of untilcorrection mobilization ofthemidfaceforward IIIosteotomyand to facialadvancementwithaLeFort facial distractionosteogenesis.First,shewassubmitted hypoplasiausingexternal maxillary thesevere correct (Z -2.1)andL1-L4of0.676g/cm²-2.4). Management ofP450oxidoreductase deficiency Pelvic ultrasound revealed an infantile uterus an infantile uterus Pelvic ultrasound revealed peripheralblood extractedfrom DNA sampleswere The patient received glucocorticoid stress dose inthe stress glucocorticoid The patient received to plasticsurgery At 15yearsold,sheunderwent

exonic

synostosis. carpal bonefusion;(C)Severeelbowrestrictionwithradio-humeral (A) Figure 1.Skeletalabnormalitiesin46,XXpatientwithPORdeficiency. is associated with a higher prevalence ofatypical is associatedwithahigher prevalence the Japanese population, the p.R457H mutation, On theotherhand,most commonmutationin genitalia. external to 46,XYpatientswhoexhibit normal genitaliavirilization,incontrast with external presented homozygousforthismutation, patients whoare alleles(8).Ourcase,andother46,XX of nonrelated 43% inapproximately Caucasians, anditisobserved mutationin homozygosis, whichisthemostfrequent reports. and previous adulthood. We describe the manifestations of our case and with genotypesandoutcomesduringpuberty emphasize theclinicalmanifestationsincorrelation by widephenotypicvariability. However, fewreports ischaracterized in2004,andthisdisorder reports first Le FortIIIadvancement. Figure 2. Facialcharacteristicsbefore(A,B,C)andafterD,E,F) surgery: Shortening ofthe4 Our patient carried thep.A287Pmutationin Our patientcarried th and5 th metatarsus;(B)arachnodactylyand Arch Metab. Endocrinol 2016;60/5 Arch Metab. Endocrinol 2016;60/5 bythePORforitscatalytic the transferofelectrons involved inoocytematuration. TheCYP51A1requires of PORDonthesynthesis and metabolismofsteroids (17). Anotherhypothesismay bethenegativeimpact gene and inactivatingmutationsoftheLHreceptor ovariancysts description ofapatientwithamenorrhea, bythe hypogonadism;which isnotsupported primary LHstimulation due to cysts includes the increased ofovarian (16). Onehypothesisfortheprevalence finding rare development untilTanner IVwasavery findings.Spontaneousbreast themostprevalent were (50%) andsparseorabsenceofpubichair(100%) development (70%),lackofbreast amenorrhea primary of46,XXpatientswithP450c17deficiency,cohort Inour is mainlyexplainedbyP450c17impairment. developmentandamenorrhea pubertal insufficient inallofthem(10).The observed ovarian cystswere delayandlarge pubertal female patientspresented seriesofsevenPORDpatients, inwhichfive previous development atageof14,whichwassimilartothe pubertal partial (10,13,15). Ourcasepresented (1). wasreported of17α-hydroxylase and impairment Notably, DOCA duetoincreased highbloodpressure inthefirst yearsoflifeinmostcases. insufficiency againstthedevelopmentof adrenocortical protects which secretion, 21-deoxycortisol with increased in somesituations.P450c17deficiencyisconsistent deficiency confused with the diagnosis of 21-hydroxylase deficiency.of 21-hydroxylase maybe Thisincrease notashighthe classicalform but theselevelsare (17OHP)levels, basal 17-hydroxyprogesterone with moderately increased these patients may present concomitant deficiencyofP450c21.Consequently, ofP450c17activitywitha is duetoimpairment (8,13). Thisphenotype hydrocortisone permanent all patientsneeded in50% those largeof cohorts, wasfoundinalmost documented bycosyntropin insufficiency ACTH-stimulation. Theadrenal after wasobserved secretion cortisol but impaired deficiency. normal, levels were cortisol Basal serum sexassignmenthavealsobeendescribed(7,14). wrong IV and V) including virilization (Prader scores severe deficiency. However, with 46,XXcasespresenting thanthe21-hydroxylase patients, whichisdifferently genitalia virilizationismoderateinmost46,XXPORD ofexternal (13).Thedegree versus 44%,respectively) genitalia in both 46,XX than 46,XY patients (100% There are few data on puberty development fewdataonpuberty are There lateonsetglucocorticoid Our patientpresented affected childforthiscoupleis25%. affected ofPORD,sincetheriskforan may havebeenreflective manifestations at the first pregnancy hyperandrogenic with PORD(7).We speculatedthatthemother’s may bethefundamentalcharacteristicsoffetuses bonedefectsdetectedbyfetalultrasound and severe virilization of maternal women found that the presence mutations. Asinglemulticenterstudyof20pregnant withspecificPOR manifestations andtheircorrelation ofmaternal onthefrequency is nodataintheliterature inthemotherof ourpatient.However, there observed appear, suchasadeepeningofthevoice,whichwas acnetohirsutismuntilvirilizationsigns range from ofPORDfetusesand describedduringpregnancies are manifestations inmothers patient. Hyperandrogenic with peers. ofsociabilityandrelationships withimprovement result and jaw. Notably, facialcosmetic thepatienthadgreat offace,orbit morphologicabnormalities they correct late, were patientsurgical procedures in this particular is between6monthsto1yearold(20);eventhough craniosynostosis to allow adequate brain development ofmidfacehypoplasiaand The idealageforcorrection notknown. in thesevariationsbonephenotypeare and thegenetic factorsinvolved this was notconfirmed; least onenullmutationinallele,butourpatient at phenotypeharbored bonemalformation severe more (8). Patients with had mild to moderate malformations andcols.homozygousforp.A287P byKrone report (8).However, score malformation thesixpatients phenotypebasedonPORD consistent withsevere femoral bowingandcamptodactyly in hands and feet nasalbridge, bilateral elbow synostosis, depressed hypoplasia, pancraniosynostosis,maxillary presented the highestvariabilityinPORDpatients.Ourcase bonemass. and improve cycle menstrual to keep regular was crucial replacement study (10). In addition, the estrogen/progestin previous LHstimulus,confirming decreased through probably andtoavoidnewcystsformation, regression cysts topromote wasefficient replacement progestin with estrogen/ maturation (18,19).Thetreatment oocyte andsupport of oocytemeiosisduringpuberty resumption essentialtopromote are activating sterols Follicular fluidmeiosis- to meiosis-activating sterols. activity, theconversionoflanosterol whichpromotes The PORD phenotype is not restricted tothe The PORDphenotypeisnotrestricted phenotype presents The bonemalformation Management ofP450oxidoreductase deficiency 503

Copyright© AE&M all rights reserved. Copyright© AE&M all rights reserved. approach infacialhypoplasia. approach andthebenefitof latesurgical at puberty steroids therapy with sex replacement the need for hormone deficiency,continuous monitoringforglucocorticoid levels.We androgen of serum theimportance stressed possibility inpatientswithgenitalambiguityandlow of this diagnostic a warning (14), and provided described thesecondPORDcaseinourpopulation multiplesystems.Wephenotypic variabilitythataffects 504 7. 6. 5. 4. 3. 2. 1. REFERENCES was reported. relevant tothisarticle nopotentialconflictofinterest Disclosure: Capes #1459789/2014. byagrantfrom CNPq# 308318/2012-9.LGGwassupported Fapesp #2014-7878-4,TASSB byagrantfrom wassupported by a grant from supported Funding: this paper was partially Management ofP450oxidoreductase deficiency onclusion, PORD is a rare diseasewithsignificant In conclusion,PORDisarare Endocrinol Metab.2013;98(3):E528-36. hyperplasia causedbyP450oxidoreductase deficiency. JClin OA, HendonLG,etal.Prenatal diagnosisofcongenitaladrenal Reisch N,IdkowiakJ, Hughes BA,IvisonHE, Abdul-Rahman p450 oxidoreductase deficiency. EndocrDev. 2011;20:63-79. Fluck CE,Pandey AV. Clinicalandbiochemical consequencesof disordered steroidogenesis. Am J Hum Genet.2005;76(5):729-49. oxidoreductase inpatientswith Antley-Bixler syndromeand andfunctionofmutationsinp450 Mowat D,etal.Diversity Huang N,Pandey AV, Agrawal V, Reardon W, LapunzinaPD, Endocrinol. 2007;21(8):1958-68. bytheP450oxidoreductase mutant activities A287P. Mol PM, etal.Differential inhibitionofCYP17A1 andCYP21A2 Dhir V, IvisonHE,KroneN,Shackleton CH,Doherty AJ, Stewart transfer. Endocrinology. 2005;146(6):2544-50. Miller WL. Minireview:regulationofsteroidogenesisbyelectron Lancet. 2004;363(9427):2128-35. oxidoreductase andhumanandrogensynthesis:analyticalstudy. et al.Congenitaladrenalhyperplasia causedbymutantP450 Arlt W, Walker EA,DraperN,IvisonHE,RideJP, HammerF, and without Antley-Bixler syndrome.NatGenet.2004;36(3):228-30. Mutant P450oxidoreductase causesdisorderedsteroidogenesiswith Fluck CE, Tajima T, Pandey AV, Arlt W, Okuhara K, Verge CF, etal. 20. 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. Craniofac Surg.2015;26(6):1735-807. of craniosynostosis:workinggrouponcraniosynostosis.J Mathijssen IM. Guidelineforcareofpatientswiththe diagnoses Suppl5:3-10. sterol.HumReprod.activating 2000;15 Human oocyte maturation in vitro is stimulated by meiosis- Grondahl C,Hansen K,OttesenTH, Marky-Nielsen JL,Hyttel P. oocyte meiosis.Nature.1995;374(6522):559-62. Wassmann O, etal.Chemicalstructure of sterols that activate Byskov AG, CY,Andersen NordholmL, H,XiaG, Thogersen 1996;334(8):507-12. of theluteinizinghormone-receptorgene.NEnglJMed. mutations to luteinizing hormone caused by inactivating Bloise W, etal.Briefreport: testicularandovarian resistance Latronico AC, Anasti J, Arnhold IJ, Rapaport R, Mendonca BB, CYP17A1 defects.Fertil Steril.2016;105(6):1612-9. of 46,XXpatientswithcongenitaladrenalhyperplasia dueto Inácio M,etal.Clinical,hormonal,ovarian, andgeneticaspects Carvalho LC,Brito VN, Martin RM,Zamboni AM, GomesLG, 3584-8. 17,20-lyase deficiency. JClinEndocrinolMetab.2008;93(9): P450 oxidoreductase inafamilypreviouslydiagnosedashaving Loewental N,etal.HomozygousmutationG539Rinthegenefor E,ParvariHershkovitz R, Wudy SA, Hartmann MF, GomesLG, Arq BrasEndocrinolMetab.2012;56(8):578-85. novel mutationsinthecytochrome P450oxidoreductase gene. Petroli RJ, etal.46,XXDSDand Antley-Bixler syndromedueto Guaragna-Filho G,CastroCC,CarvalhoRR,CoeliFB,Ferraz LF, Metab. 2009;94(5):1723-31. phenotype correlations in35Japanese patients.JClinEndocrinol and characterization ofbiallelicmutationsandgenotype- et al.Cytochrome P450oxidoreductase deficiency:identification Fukami M,NishimuraG,HommaK,Nagai T, HanakiK,Uematsu A, 2010;21(5):1560-4. PJ. Spectrumof Antley-Bixler syndrome.JCraniofacSurg. McGlaughlin KL, Witherow H,Dunaway DJ, DavidDJ, Anderson oxidoreductase deficiency. Horm Res. 2008;69(5):266-75. Scott RR,Miller WL. Geneticandclinicalfeaturesofp450 deficiency. JClinEndocrinolMetab.2011;96(3):E453-62. congenital adrenal hyperplasia due to P450 oxidoreductase Kerstens MN,etal.Pubertal presentationinsevenpatientswith Idkowiak J, O’RiordanS,Reisch N,MalunowiczEM,CollinsF, sexual differentiation. MolCellEndocrinol.2013;371(1-2):124-32. and men: “Backdoor” dihydrotestosterone synthesisinmale Biason-Lauber A, Miller WL, Pandey AV, Fluck CE.Ofmarsupials 2012;97(2):E257-67. due toP450oxidoreductase deficiency. JClinEndocrinolMetab. Genotype-phenotype analysisincongenitaladrenalhyperplasia Krone N,Reisch N,IdkowiakJ, Dhir V, IvisonHE,HughesBA,etal. Arch Metab. Endocrinol 2016;60/5