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| {{Congenital adrenal hyperplasia}} | | {{Congenital adrenal hyperplasia}} |
| | ==Classification== |
| | Congenital adrenal hyperplasia is classified into seven types based on the genetic causes that lead to hyperplasia and hormonal imbalance. |
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| {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}} | | {| align="center" class="wikitable" style="border: 0px; font-size: 90%; margin: 3px;" |
| | ! align="center" style="background:#DCDCDC;" rowspan="2" colspan="2" |Disease |
| | ! align="center" style="background:#DCDCDC;" colspan="2" |History and symptoms |
| | ! align="center" style="background:#DCDCDC;" colspan="3" |Laboratory findings |
| | ! align="center" style="background:#DCDCDC;" |Defective gene |
| | |- |
| | !Blood pressure |
| | !Genitalia |
| | !Increased |
| | !Decreased |
| | !K levels |
| | ! |
| | |- |
| | | align="center" style="padding: 5px 5px; background: #DCDCDC;" rowspan="2" |[[21-hydroxylase deficiency]] |
| | |Classic type |
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| | * Low in salt-wasting |
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| ==Overview==
| | * Normal in non-salt-wasting |
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| | * Female: ambiguous |
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| ==Types of CAH==
| | * Male: normal or scrotal pigmentation and large phallus |
| [[Image:DHEA1_svg.png|thumb|300px|Production of DHEA from Cholesterol. ([[Cortisol]] is a [[glucocorticoid]].)]] {{-}}
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| | | * [[Deoxycorticosterone]] |
| [[Cortisol]] is an adrenal [[steroid hormone]] necessary for life; production begins in the second month of fetal life. Inefficient cortisol production results in rising levels of [[adrenocorticotropic hormone|ACTH]], which in turn induces overgrowth (''hyperplasia'') and overactivity of the [[steroid]]-producing cells of the adrenal cortex. The defects causing adrenal hyperplasia are ''congenital'' (i.e., present at birth). | | * 11-Deoxy-[[cortisol]] |
| | | * [[17-Hydroxyprogesterone|17-hydroxyprogesterone]], mild elevation |
| Cortisol deficiency in CAH is usually partial, and not the most serious problem for an affected person. Synthesis of cortisol shares steps with synthesis of [[mineralocorticoid]]s such as [[aldosterone]], [[androgen]]s such as [[testosterone]], and [[estrogen]]s such as [[estradiol]]. The resulting excessive or deficient production of these three classes of hormones produce the most important problems for people with CAH. Specific enzyme inefficiencies are associated with characteristic patterns of over- or underproduction of mineralocorticoids or [[sex steroid]]s.
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| | | * [[Cortisol]] |
| In all its forms, [[congenital adrenal hyperplasia due to 21-hydroxylase deficiency]] accounts for about 95% of diagnosed cases of CAH. Unless another specific enzyme is mentioned, "CAH" in nearly all contexts refers to [[21-hydroxylase]] deficiency.
| | * [[Corticosterone]] |
| *Severe 21-hydroxylase deficiency causes '''''salt-wasting CAH''''', with life-threatening vomiting and [[dehydration]] occurring within the first weeks of life. Severe 21-hydroxylase deficiency is also the most common cause of [[ambiguous genitalia]] due to prenatal [[virilization]] of genetically female (XX) infants.
| | * [[Aldosterone]] |
| *Moderate 21-hydroxylase deficiency is referred to as '''''simple virilizing CAH'''''; and typically is recognized by causing virilization of prepubertal children.
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| *Still milder forms of 21-hydroxylase deficiency are referred to as '''''non-classical CAH''''' and can cause [[androgen]] effects and [[infertility]] in adolescent and adult women. | | * High in salt wasting type |
| | | * Normal in non salt wasting |
| CAH due to deficiencies of enzymes other than 21-hydroxylase present many of the same management challenges as 21-hydroxylase deficiency, but some involve [[mineralocorticoid]] excess or [[sex steroid]] deficiency.
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| *[[Lipoid congenital adrenal hyperplasia]] | | * CYP21A1 and CYP21A2 gene |
| *[[Congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency|Congenital adrenal hyperplasia due to 17α-hydroxylase deficiency]] | | |- |
| *[[Congenital adrenal hyperplasia due to 3 beta-hydroxysteroid dehydrogenase deficiency|Congenital adrenal hyperplasia due to 3β-hydroxysteroid dehydrogenase deficiency]] | | |Non-classic type |
| *[[Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency|Congenital adrenal hyperplasia due to 11β-hydroxylase deficiency]]
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| | | * Normal |
| Further variability is introduced by the degree of [[enzyme]] inefficiency produced by the specific [[allele]]s each patient has. Some alleles result in more severe degrees of enzyme inefficiency. In general, severe degrees of inefficiency produce changes in the fetus and problems in prenatal or perinatal life. Milder degrees of inefficiency are usually associated with excessive or deficient [[sex steroid|sex hormone]] effects in childhood or adolescence, while the mildest form of CAH interferes with ovulation and [[fertility]] in adults.
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| | * Female: virilization after puberty |
| | * Male: normal appearance |
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| | * [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] |
| | * Exaggerated [[Androstenedione]], [[DHEA]], and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] |
| | response to [[ACTH]] |
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| | * Normal |
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| | * CYP21A1 and CYP21A2 gene |
| | |- |
| | | align="center" style="padding: 5px 5px; background: #DCDCDC;" colspan="2" |[[17 alpha-hydroxylase deficiency|17-α hydroxylase deficiency]] |
| | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | * Hypertension |
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| | * Female: normal |
| | * Male: ambiguous |
| | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | * [[Deoxycorticosterone]] |
| | * [[Corticosterone]] |
| | * [[Progesterone]] |
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| | * [[Cortisol]] |
| | * [[Aldosterone]] |
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| | * Low |
| | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | * CYP17A1 |
| | |- |
| | | align="center" style="padding: 5px 5px; background: #DCDCDC;" colspan="2" |[[11β-hydroxylase deficiency|11-β hydroxylase deficiency]] |
| | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | * Hypertension |
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| | * Female: ambiguous |
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| Finally, specific problems may also differ with the genetic [[Gender|sex]] of the affected person. For example, the most common type of CAH, due to deficient 21-hydroxylase activity, can produce [[ambiguous genitalia]] in XX fetuses but not XY.
| | * Male: normal or scrotal pigmentation and large phallus |
| | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| Treatment of all forms of CAH may include any of:
| | * [[Deoxycorticosterone]] |
| # supplying enough [[glucocorticoid]] to reduce hyperplasia and overproduction of [[androgen]]s or [[mineralocorticoid]]s
| | * 11-Deoxy-[[cortisol]] |
| # providing replacement mineralocorticoid and extra salt if the person is deficient
| | * [[17-Hydroxyprogesterone|17-hydroxyprogesterone]], mild elevation |
| # providing replacement [[testosterone]] or [[estrogen]] at puberty if the person is deficient | | | |
| # additional treatments to optimize growth by delaying puberty or delaying [[bone maturation]]
| | * [[Cortisol]] |
| # [[genital reconstructive surgery]] to correct problems produced by abnormal genital structure
| | * [[Corticosterone]] |
| | | * [[Aldosterone]] |
| All of these management issues are discussed in more detail in [[congenital adrenal hyperplasia due to 21-hydroxylase deficiency]].
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| | | * Low |
| ===Genetics===
| | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| All involved [[genes]] are autosomal. See the table under 'Biochemistry' subheading for [[chromosome|chromosomal]] locations.
| | * CYP11B1 |
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| Because they code for [[enzyme]]s with amplifiable activity, noticeable effects only occur in people with two defective [[allele]]s of these [[gene]]s. Hundreds of different allelic [[mutation]]s of these genes have been reported. Nearly always, each parent of an affected person is an unaffected [[heterozygote]] (i.e., [[asymptomatic carrier]] of one defective gene and one normal gene and has no ill effects). Each child of that pair of parents has a 25% chance of being affected, "having CAH". [[Prenatal diagnosis]] and heterozygote detection are now possible.
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| Although mutations leading to the various forms of CAH have been found all over the world, there are substantial differences in the carrier rates of specific abnormal alleles in different regions and ethnic groups.
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| ===Biochemistry===
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| {| style="border-collapse:collapse" border=1 cellpadding=5
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| |- style="background-color:#ccc"
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| | '''Common medical term''' | |
| | '''OMIM no.'''
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| | '''Enzyme(s)'''
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| | '''Gene location'''
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| | '''Substrate(s)'''
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| | '''Product(s)'''
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| | [[Congenital adrenal hyperplasia due to 21-hydroxylase deficiency|21-hydroxylase CAH]] | | | align="center" style="padding: 5px 5px; background: #DCDCDC;" colspan="2" |3β-Hydroxysteroid Dehydrogenase |
| | {{OMIM|201910}} | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | P450c21 | | | |
| | 6p21.3 | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | 17OH-progesterone→<br/>[[progesterone]]→
| | * [[Dehydroepiandrosterone]] |
| | 11-deoxycortisol<br/>[[11-deoxycorticosterone|DOC]] | | * [[17-hydroxypregnenolone]] |
| | * [[Pregnenolone]] |
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| | * [[Cortisol]] |
| | * [[Aldosterone]] |
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| | * High |
| | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| |- | | |- |
| | [[Lipoid congenital adrenal hyperplasia|lipoid CAH]]<br/>(20,22-desmolase) | | | align="center" style="padding: 5px 5px; background: #DCDCDC;" colspan="2" |Cytochrome P450-oxidoreductase (POR) deficiency (ORD) |
| | {{OMIM|201710}} | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | StAR<br/>P450scc | | | |
| | 8p11.2<br/>15q23-q24 | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | transport of [[cholesterol]]<br/>[[cholesterol]]→ | | | |
| | into mitochondria<br/>[[pregnenolone]] | | | |
| | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| |- | | |- |
| | [[Congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency|17α-hydroxylase CAH]] | | | align="center" style="padding: 5px 5px; background: #DCDCDC;" colspan="2" |Congenital lipoid adrenal hyperplasia |
| | {{OMIM|202110}} | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | P450c17 | | | |
| | 10q24.3 | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | [[pregnenolone]]→<br/>[[progesterone]]→<br/>17OH-pregnenolone→ | | | |
| | 17OH-pregnenolone<br/>17OH-progesterone<br/>[[DHEA]] | | | |
| | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| |- | | |- |
| | [[Congenital adrenal hyperplasia due to 3 beta-hydroxysteroid dehydrogenase deficiency|3β-HSD CAH]] | | | align="center" style="padding: 5px 5px; background: #DCDCDC;" colspan="2" |Cholesterol side-chain cleavage enzyme deficiency |
| | {{OMIM|201810}} | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | 3βHSD II | | | |
| | 1p13 | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | [[pregnenolone]]→<br/>17OH-pregnenolone→<br/>[[DHEA]]→ | | | |
| | [[progesterone]]<br/>17OH-progesterone<br/>[[androstenedione]] | | | |
| |- | | | align="center" style="padding: 5px 5px; background: #F5F5F5;" | |
| | [[Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency|11β-hydroxylase CAH]] | |
| | {{OMIM|202010}}
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| | P450c11β
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| | 8q21-22
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| | 11-deoxycortisol→<br/>DOC→
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| | [[cortisol]]<br/>[[corticosterone]] | |
| |} | | |} |
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| Abbreviations:
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| * OMIM no. is [[Online Mendelian Inheritance in Man]] index number
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| * StAR is [[steroidogenic acute regulatory protein]]
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| * HSD is hydroxysteroid dehydrogenase.
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| * P450scc is [[cytochrome]] P450 [[side chain]] cleavage enzyme.
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| * 17OH-progesterone and 17OHP are [[17-hydroxyprogesterone]].
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| * 17OH-pregnenolone is [[17-hydroxypregnenolone]]
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| * DHEA is [[dehydroepiandrosterone]].
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| * DOC is [[deoxycorticosterone]].
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| Since the 1960s most endocrinologists have referred to the forms of CAH by the traditional names in the left column, which generally correspond to the deficient enzyme activity. As exact structures and genes for the enzymes were identified in the 1980s, most of the enzymes were found to be [[cytochrome P450 oxidase]]s and were renamed to reflect this. In some cases, more than one enzyme was found to participate in a reaction, and in other cases a single enzyme mediated in more than one reaction. There was also variation in different tissues and mammalian species.
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| ==References==
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| {{Reflist|2}}
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| [[Category:Disease]]
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| [[Category:Pediatrics]]
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| [[Category:Endocrinology]]
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| [[Category:Genetic disorders]]
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