European Journal of Endocrinology (2013) 168 K45–K50 ISSN 0804-4643 CASE REPORT A man with a DAX1/NR0B1 mutation, normal puberty, and an intact hypothalamic–pituitary–gonadal axis but deteriorating oligospermia during long-term follow-up Marie-Laure Raffin-Sanson1,2,Be´re´nice Oudet1, Sylvie Salenave3, Sylvie Brailly-Tabard3,4, Martine Pehuet1, Sophie Christin-Maitre5, Yves Morel6 and Jacques Young3,4 1Service d’Endocrinologie, Assistance Publique- Hoˆpitaux de Paris, Hoˆpital Ambroise Pare´, 92100 Boulogne, France, 2EA2493, Universite´ de Versailles- Saint Quentin en Yvelines, 78035 Versailles, France, 3Universite´ Paris Sud 11, Service d’Endocrinologie et des Maladies de la Reproduction, Hoˆpital Biceˆtre and Assistance Publique- Hoˆpitaux de Paris, 94270 Le Kremlin Biceˆtre cedex, France, 4INSERM U 693, F-94275 Le Kremlin Biceˆtre, France, 5Service d’Endocrinologie de la reproduction, Hoˆpital Saint Antoine et Faculte´ Paris VI, Paris, France and 6Biochimie Endocrinienne et Biologie Mole´culaire, Hoˆpital Debrousse, Lyon, France (Correspondence should be addressed to J Young; Email: [email protected]) Abstract Objective: DAX1/NR0B1 mutations cause primary adrenal insufficiency in early childhood and hypogonadotropic hypogonadism (HHG), leading to absent or incomplete sexual maturation. The aim of the study was to prospectively investigate gonadotrope and testicular functions in a patient carrying a DAX1 mutation, who had spontaneous puberty and normal virilization but oligospermia. Case report: The proband was referred for infertility at the age of 32 years. He reported adrenal insufficiency diagnosed at the age of 19 years. Puberty started at the age of 13 years, with spontaneous virilization, growth spurt, and testicular growth. He reported normal libido and sexual function. Physical examination showed normal virilization, penile length, and testicular volume. However, semen samples showed severe oligospermia. Hormonal measurements confirmed adrenal insufficiency but showed a preserved hypothalamic–pituitary–gonadal axis with normal testosterone and inhibin B; basal and GNRH-stimulated gonadotropin levels and LH pulsatility were also normal. He fathered a first boy by in vitro fertilization and a second boy without medical assistance. As a nephew also had early adrenal insufficiency, the possibility of DAX1 mutation was raised. The same recurrent hemizygous nonsense mutation W39X was found in the proband, his nephew, and in an apparently asymptomatic brother who was found to have adrenal insufficiency, mild HHG, and azoospermia. Several evaluations of the proband over 20 years showed preserved testosterone levels and LH secretion but deteriorating oligospermia. Conclusion: Long-term preservation of normal hypothalamic–pituitary–gonadal function in this patient, contrasting with his severe oligospermia, strongly suggests that DAX1 is required for human spermatogenesis, independently of its known role in gonadotropin secretion. European Journal of Endocrinology 168 K45–K50 Introduction this mutation. However, it is unclear whether or not the effect of DAX1 mutations on human spermatogenesis DAX1 (for dosage-sensitive sex reversal, adrenal is due solely to the associated gonadotropin deficiency. hypoplasia congenital (AHC) critical region on the Milder forms of the disease have been described, with X chromosome, gene 1; also called NR0B1)mutations adrenal insufficiency sometimes occurring in childhood can cause congenital adrenal hypoplasia, a rare X-linked or even early adulthood. A few cases of partial HHG have disorder associated with impaired development of the also been described, with clear clinical and biological permanentzonesoftheadrenalcortex,usuallyrevealedby signs but no subjective symptoms (4, 5). Rare cases of primary adrenal failure in early infancy (1, 2). Hypogona- apparently preserved gonadotropin secretion have been dotropic hypogonadism (HHG) is also a hallmark of this reported but not fully documented in patients with DAX1 disorder, usually recognized during adolescence because mutations (6, 7). of the absence or interruption of normal pubertal devel- Here, we report the initial features and long-term opment (1). HHG due to DAX1 mutation results from outcome of a 32-year-old man diagnosed with adrenal a combination of defective hypothalamic GNRH release insufficiency at the age of 19 years, who had oligo- and defective pituitary gonadotropin production (3). spermia but persistently normal gonadotropic function. Abnormal spermatogenesis is also noted in patients with Molecular analysis revealed the same hemizygous q 2013 European Society of Endocrinology DOI: 10.1530/EJE-12-1055 Online version via www.eje-online.org Downloaded from Bioscientifica.com at 10/01/2021 01:52:34AM via free access K46 M-L Raffin-Sanson and others EUROPEAN JOURNAL OF ENDOCRINOLOGY (2013) 168 of sore throat and dizziness. He was treated effectively with hydrocortisone and fluorocortisone. He also Heterozygous TAG/TGG I - 1 I - 2 (W39X/WT) reported being diagnosed with oligospermia at the age of 24 years, following failure to conceive, but denied further investigations at that time. II - 1 II - 2 II - 3 At the first hormonal evaluation at the age of Hemizygous for TGG 32 years, his height was 171 cm, his weight 83 kg, (W39X) and his blood pressure 130/70 mmHg. Physical exami- ? nation revealed increased skin pigmentation. Penile III - 1 III - 2 III - 3 III - 4 length was normal (10 cm). Testicular volume was 20 ml bilaterally (normal range 12–30 ml). He reported Hemizygous for TGG (W39X) spontaneous onset of puberty at the age of 13 years, with normal virilization, growth spurt, and testicular Figure 1 Pedigree of the family with patients affected by AHC growth. He reported normal libido, erections, and with mutated DAX1 gene. Symbols represent males (squares), sexual function. At the time of the initial investigations, females (circles), affected subjects (solid symbols), carriers (dashed symbols), and the proband (arrow). DNA sequencing and mutation at 30 years of age, he was taking hydrocortis- analysis were performed as described in (22), with minor modifi- one 30 mg/day and 9a-fluorocortisone 100 mg/day. cations. WT, wild type. The propositus is indicated by an arrow. Biological and hormonal explorations confirmed the primary adrenal insufficiency (Table 1). Adrenoleuko- dystrophy was ruled out by a normal level of C24/C22 N-terminal nonsense DAX1 mutation (W39X) in the very-long-chain fatty acids. Computed tomography proband, his young nephew and, a few years later, in showed bilateral adrenal atrophy. During this period, his brother. The proband finally fathered two children. the proband’s sister (subject II-1, Fig. 1) gave birth to a This is the first reported case of long-term preservation boy who had normal descended testes and normal of gonadotrope function in a patient with markedly genitalia (subject III-1, Fig. 1) but who had an adrenal defective spermatogenesis due to DAX1 mutation. crisis (Na 122 mmol/l, KC7.7 mmol/l) during the second week of life. The newborn had elevated plasma ACTH and renin levels, confirming primary adrenal Case report insufficiency. The possibility of a DAX1 mutation was therefore raised and molecular studies of the patient The proband (subject II-2, Fig. 1) was referred to the and his nephew were performed with the patient’s and Endocrinology Department of Biceˆtre Hospital, Paris, at parents’ informed consent. A nonsense loss-of-function 32 years of age for evaluation of oligospermia. Adrenal (8) mutation in the DAX1 gene, resulting in an amino- insufficiency had been diagnosed at the age of 19 years, terminal truncated protein (W39X: TAG/TGG), was when he presented with fatigue and repeated episodes found in both subjects. The same mutation was found Table 1 Hormonal and gonadal evaluation of the proband (subject II-2 in Fig. 1) at diagnosis and during follow-up. The brother (subject II-3 in Fig. 1) was evaluated at diagnosis. Proband Brother 1987 1997 2000 2002 2003 2008 2012 2011 (23 years) (32 years) (35 years) (37 years) (39 years) (43 years) (47 years) (36 years) Normal range Cortisol (0800 h) – 0.5 – 0.6 0.6 !0.2 0.5 10 9–23 (mg/100 ml) ACTH (0800 h) – 2315 – 1671 1414 2843 2014 749 10–50 (pg/ml) DHEAS – 361 – 249 268 200 – 147 800–4500 (ng/ml) Renin (supine/ – 464/690 – –/320 310/310 491/– 500 – 3–16/3–33 (pg/ml) upright) Aldosterone – 75/76 – –/65 60/70 13/– 30 12/28 15–150/35–350 (supine/upright) (pg/ml) Testosterone 7.7 5.5 6.1 5.2 5.4 4.2 5.3 2.4 3.5–8.5 (ng/ml) LH (basal/ 6.3/– 2.4/9.4 1.7/8.6 – 1.3/10.5 2.6/7.5 1.8/– 2/5.6 1.5–12.4/8.0–25 stimulateda) (IU/l) FSH (basal/ 5.8/– 4.1/5.6 3.4/5.0 – 1.2/4.0 4.4/8.7 4.4/– 5.9/7.3 1.7–8.6/2.0–9.0 stimulateda) (IU/l) Inhibin B – – 148 123 113 38 – 74 80–270 (pg/ml) Sperm count 4!106 2.3!106 0.7!106 0.05!106 –––0O20!106/ml Serum LH and FSH were measured by immunofluorometric assay, testosterone levels by RIA, and inhibin B levels with an ELISA method as described previously (24). –, not done. aGNRH (100 mg i.v.), the GNRH challenge test was performed as reported in (24). Plasma renin, aldosterone, DHEAS, ACTH, and cortisol levels were determined with commercial RIA kits. www.eje-online.org Downloaded from Bioscientifica.com at 10/01/2021 01:52:34AM via free access EUROPEAN JOURNAL OF ENDOCRINOLOGY (2013) 168 DAX1 mutation with function K47 in the unaffected proband’s mother (subject I-1, Fig. 1) and sister (subject II-1, Fig. 1), and both were heterozygous. A 3.5 Proband: subject II-2 Results of longitudinal evaluation of the proband * 3 are shown in Table 1 and Fig. 2A. The plasma total Age: 32 years testosterone level remained normal throughout the 2.5 TV: 20 ml 25 years of follow-up, indicating LH-driven preserved T: 5.5 ng/ml Leydig cell function.