Abstract
Objectives
The 5α-reductase-type-2 deficiency (5ARD2) is a rare autosomal recessive 46,XY disorder of sex development caused by the mutated 5α-reductase type 2 (SRD5A2) gene. In this disease, defective conversion of testosterone to dihydrotestosterone leads to variable presentations of male ambiguous genitalia during fetal development. We aimed to examine characteristics of patients presenting with 5ARD2 over a 4 year period.
Methods
Random urine samples of control and patients with suspected 5ARD2 were collected and urine steroidomic metabolites were measured by Gas chromatography-mass spectrometry (GC-MS) in the period from 2017 to 2021 at National Children’s Hospital, Hanoi Vietnam. 5α- to 5β-reduced steroid metabolite ratio, 5a-tetrahydrocortisol to tetrahydrocortisol (5α-THF/THF), was reviewed by receive operator characteristics (ROC) curve analysis. Molecular testing was offered to 25 patients who were diagnosed with 5ARD2 by GC-MS urinary steroid analysis.
Results
Urine steroidomic profiling was conducted for 104 male controls and 25 patients between the ages of 6 months and 13 years old. Twelve of the twenty-five 5ARD2 patients agreed to undertake genetic analysis, and two mutations of the SRD5A2 gene were detected in each patient, confirming the diagnosis. All patients showed a characteristically low ratio of 5α-THF/THF. There was no overlap of 5α-THF/THF ratio values between control and 5ARD2 groups. The ROC of 5α-THF/THF ratio at 0.19 showed 100% sensitivity and 100% specificity for boys between 6 months and 13 years of age.
Conclusions
Analysis of the urine steroid metabolome by GC-MS can be used to assist in the diagnosis of 5ARD2. We recommend consideration of random urine steroid analysis as a first-line test in the diagnosis of 5ARD2.
Funding source: Asia Pacific Federation of Clinical Chemistry and Laboratory Medicine project grant.
Acknowledgments
We sincerely thank the children and their families who agreed to participate in this study. We acknowledge the Asia-Pacific Federation of Clinical Biochemistry and Laboratory Medicine for funding of the urine steroid metabolome method development. We also would like to thank the TRAC (Training and Research Academic Collaboration) Sweden-Vietnam for funding the SRD5A2 gene mutation analysis study.
-
Research funding: Asia Pacific Federation of Clinical Chemistry and Laboratory Medicine project grant.
-
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
-
Competing interests: Authors state no conflict of interest.
-
Informed consent: Written informed consent was obtained from all individuals included in this study.
-
Ethical approval: Ethics approval for collection and analysis of urine samples was obtained from the Ethics Committee of the Vietnam National Children’s Hospital, Hanoi Vietnam.
References
1. Honour, JW, Brook, CG. Clinical indications for the use of urinary steroid profiles in neonates and children. Ann Clin Biochem 1997;34:45–54. https://doi.org/10.1177/000456329703400107.Search in Google Scholar PubMed
2. Shackleton, C. Clinical steroid mass spectrometry: a 45 year history culminating in HPLC–MS/MS becoming an essential tool for patient diagnosis. J Steroid Biochem Mol Biol 2010;121:481–90. https://doi.org/10.1016/j.jsbmb.2010.02.017.Search in Google Scholar PubMed
3. Wudy, SA, Schuler, G, Sánchez-Guijo, A, Hartmann, MF. The art of measuring steroids: principles and practice of current hormonal steroid analysis. J Steroid Biochem Mol Biol 2018;179:88–103. https://doi.org/10.1016/j.jsbmb.2017.09.003.Search in Google Scholar PubMed
4. Greaves, RF, Jevalikar, G, Hewitt, JK, Zacharin, MR. A guide to understanding the steroid pathway: new insights and diagnostic implications. Clin Biochem 2014;47:5–15. https://doi.org/10.1016/j.clinbiochem.2014.07.017.Search in Google Scholar PubMed
5. Kulle, A, Krone, N, Holterhus, PM, Schuler, G, Greaves, RF, Juul, A, et al.. Steroid hormone analysis in diagnosis and treatment of DSD: position paper of EU COST Action BM 1303 ‘DSDnet. Eur J Endocrinol 2017;176:P1–p9. https://doi.org/10.1530/eje-16-0953.Search in Google Scholar PubMed PubMed Central
6. Azzouni, F, Godoy, A, Li, Y, Mohler, J. The 5 alpha-reductase isozyme family: a review of basic biology and their role in human diseases. Adv Urol 2012;2012:530121. https://doi.org/10.1155/2012/530121.Search in Google Scholar PubMed PubMed Central
7. Imperato-McGinley, J, Guerrero, L, Gautier, T, Peterson, RE. Steroid 5alpha-reductase deficiency in man: an inherited form of male pseudohermaphroditism. Science 1974;186:1213–5. https://doi.org/10.1126/science.186.4170.1213.Search in Google Scholar PubMed
8. Wilson, JD, Griffin, JE, Russell, DW. Steroid 5 alpha-reductase 2 deficiency. Endocr Rev 1993;14:577–93. https://doi.org/10.1210/edrv-14-5-577.Search in Google Scholar PubMed
9. Maimoun, L, Philibert, P, Cammas, B, Audran, F, Bouchard, P, Fenichel, P, et al.. Phenotypical, biological, and molecular heterogeneity of 5alpha-reductase deficiency: an extensive international experience of 55 patients. J Clin Endocrinol Metab 2011;96:296–307. https://doi.org/10.1210/jc.2010-1024.Search in Google Scholar PubMed
10. Baldinotti, F, Majore, S, Fogli, A, Marrocco, G, Ghirri, P, Vuerich, M, et al.. Molecular characterization of 6 unrelated Italian patients with 5alpha-reductase type 2 deficiency. J Androl 2008;29:20–8. https://doi.org/10.2164/jandrol.107.002592.Search in Google Scholar PubMed
11. Ko, JM, Cheon, CK, Kim, GH, Kim, SH, Kim, KS, Yoo, HW. Clinical characterization and analysis of the SRD5A2 gene in six Korean patients with 5alpha-reductase type 2 deficiency. Horm Res Paediatr 2010;73:41–8. https://doi.org/10.1159/000271915.Search in Google Scholar
12. Maimoun, L, Philibert, P, Cammas, B, Audran, F, Pienkowski, C, Kurtz, F, et al.. Undervirilization in XY newborns may hide a 5α-reductase deficiency: report of three new SRD5A2 gene mutations. Int J Androl 2010;33:841–7. https://doi.org/10.1111/j.1365-2605.2009.01036.x.Search in Google Scholar
13. Perry, RJ, Novikova, E, Wallace, AM, Donaldson, MD. Pitfalls in the diagnosis of 5α-reductase type 2 deficiency during early infancy. Horm Res Paediatr 2011;75:380–2. https://doi.org/10.1159/000324646.Search in Google Scholar
14. Chan, AO, But, BW, Lau, GT, Lam, AL, Ng, KL, Lam, YY, et al.. Diagnosis of 5alpha-reductase 2 deficiency: a local experience. Hong Kong Med J 2009;15:130–5.Search in Google Scholar
15. Imperato-McGinley, J, Gautier, T, Peterson, RE, Shackleton, C. The prevalence of 5 alpha-reductase deficiency in children with ambiguous genitalia in the Dominican Republic. J Urol 1986;136:867–73. https://doi.org/10.1016/s0022-5347(17)45108-1.Search in Google Scholar
16. Tran, MT, Baglin, J, Tran, TT, Hoang, KT, Phung, LT, Read, A, et al.. Development of a new biochemical test to diagnose and monitor neuroblastoma in Vietnam: homovanillic and vanillylmandelic acid by gas chromatography-mass spectrometry. Clin Biochem 2014;47:206–15. https://doi.org/10.1016/j.clinbiochem.2013.11.016.Search in Google Scholar PubMed
17. Tran, MTC, Tran, NAT, Nguyen, PM, Vu, CD, Tran, MD, Ngo, DN, et al.. 11β-hydroxylase deficiency detected by urine steroid metabolome profiling using gas chromatography-mass spectrometry. Clinical Mass Spectrometry 2018;7:1–5. https://doi.org/10.1016/j.clinms.2017.12.001.Search in Google Scholar
18. Greaves, R, Poomthavorn, P, Zacharin, M. 11beta-hydroxylase deficiency masked by alternative medicines. J Paediatr Child Health 2006;42:652–4. https://doi.org/10.1111/j.1440-1754.2006.00925.x.Search in Google Scholar PubMed
19. Honour, JW. Steroid profiling. Ann Clin Biochem 1997;34:32–44. https://doi.org/10.1177/000456329703400106.Search in Google Scholar PubMed
20. Nie, M, Zhou, Q, Mao, J, Lu, S, Wu, X. Five novel mutations of SRD5A2 found in eight Chinese patients with 46,XY disorders of sex development. Mol Hum Reprod 2011;17:57–62. https://doi.org/10.1093/molehr/gaq072.Search in Google Scholar PubMed
21. Adiyaman, PB, Ocal, G, Cetinkaya, E, Akar, N, Uysal, A, Duman, T, et al.. 5 alpha steroid reductase deficiency in Turkey. Pediatr Endocrinol Rev 2006;3(3 Suppl):462–9.Search in Google Scholar
22. Boudon, C, Lobaccaro, JM, Lumbroso, S, Ogur, G, Ocal, G, Belon, C, et al.. A new deletion of the 5 alpha-reductase type 2 gene in a Turkish family with 5 alpha-reductase deficiency. Clin Endocrinol (Oxf) 1995;43:183–8. https://doi.org/10.1111/j.1365-2265.1995.tb01913.x.Search in Google Scholar PubMed
23. Boudon, C, Lumbroso, S, Lobaccaro, JM, Szarras-Czapnik, M, Romer, TE, Garandeau, P, et al.. Molecular study of the 5 alpha-reductase type 2 gene in three European families with 5 alpha-reductase deficiency. J Clin Endocrinol Metab 1995;80:2149–53. https://doi.org/10.1210/jcem.80.7.7608269.Search in Google Scholar PubMed
24. Hafez, M, Mazen, I, Ghali, I, Sultan, C, Lumbroso, S. A new mutation of 5-alpha-reductase type 2 (A62E) in a large Egyptian kindred. Horm Res 2003;59:281–4. https://doi.org/10.1159/000070626.Search in Google Scholar PubMed
25. Mazen, I, Gad, YZ, Hafez, M, Sultan, C, Lumbroso, S. Molecular analysis of 5alpha-reductase type 2 gene in eight unrelated Egyptian children with suspected 5alpha-reductase deficiency: prevalence of the G34R mutation. Clin Endocrinol (Oxf) 2003;58:627–31. https://doi.org/10.1046/j.1365-2265.2003.01763.x.Search in Google Scholar PubMed
26. Ocal, G, Adiyaman, P, Berberoğlu, M, Cetinkaya, E, Akar, N, Uysal, A, et al.. Mutations of the 5alpha-steroid reductase type 2 gene in six Turkish patients from unrelated families and a large pedigree of an isolated Turkish village. J Pediatr Endocrinol Metab 2002;15:411–21. https://doi.org/10.1515/jpem.2002.15.4.411.Search in Google Scholar PubMed
27. Skordis, N, Patsalis, PC, Bacopoulou, I, Sismani, C, Sultan, C, Lumbroso, S. 5alpha-reductase 2 gene mutations in three unrelated patients of Greek Cypriot origin: identification of an ancestral founder effect. J Pediatr Endocrinol Metab 2005;18:241–6. https://doi.org/10.1515/jpem.2005.18.3.241.Search in Google Scholar PubMed
28. Thigpen, AE, Davis, DL, Milatovich, A, Mendonca, BB, Imperato-McGinley, J, Griffin, JE, et al.. Molecular genetics of steroid 5 alpha-reductase 2 deficiency. J Clin Invest 1992;90:799–809. https://doi.org/10.1172/jci115954.Search in Google Scholar
29. Bertelloni, S, Scaramuzzo, RT, Parrini, D, Baldinotti, F, Tumini, S, Ghirri, P. Early diagnosis of 5alpha-reductase deficiency in newborns. Sex Dev 2007;1:147–51. https://doi.org/10.1159/000102103.Search in Google Scholar PubMed
30. Chan, AO, But, BW, Lee, CY, Lam, YY, Ng, KL, Tung, JY, et al.. Diagnosis of 5alpha-reductase 2 deficiency: is measurement of dihydrotestosterone essential? Clin Chem 2013;59:798–806. https://doi.org/10.1373/clinchem.2012.196501.Search in Google Scholar PubMed
31. Walter, KN, Kienzle, FB, Frankenschmidt, A, Hiort, O, Wudy, SA, van der Werf-Grohmann, N, et al.. Difficulties in diagnosis and treatment of 5alpha-reductase type 2 deficiency in a newborn with 46,XY DSD. Horm Res Paediatr 2010;74:67–71. https://doi.org/10.1159/000313372.Search in Google Scholar PubMed
32. Bertelloni, S, Russo, G, Baroncelli, GI. Human chorionic gonadotropin test: old uncertainties, new perspectives, and value in 46,XY disorders of sex development. Sex Dev 2018;12:41–9. https://doi.org/10.1159/000481552.Search in Google Scholar PubMed
33. Kamrath, C, Wudy, SA, Krone, N. Steroid biochemistry. Endocr Dev 2014;27:41–52. https://doi.org/10.1159/000363612.Search in Google Scholar PubMed
34. Taieb, J, Mathian, B, Millot, F, Patricot, MC, Mathieu, E, Queyrel, N, et al.. Testosterone measured by 10 immunoassays and by isotope-dilution gas chromatography-mass spectrometry in sera from 116 men, women, and children. Clin Chem 2003;49:1381–95. https://doi.org/10.1373/49.8.1381.Search in Google Scholar PubMed
35. Marzuki, NS, Idris, FP, Kartapradja, HD, Harahap, AR, Batubara, JRL. Characterising SRD5A2 gene variants in 37 Indonesian patients with 5-alpha-reductase type 2 deficiency. Internet J Endocrinol 2019;2019:7676341. https://doi.org/10.1155/2019/7676341.Search in Google Scholar PubMed PubMed Central
Supplementary Material
The online version of this article offers supplementary material (https://doi.org/10.1515/cclm-2022-0272).
© 2022 Walter de Gruyter GmbH, Berlin/Boston
