title: Combined 21- and 11 beta-hydroxylase deficiency in familial congenital adrenal hyperplasia.
abstract: Studies in three families (A, B, and C) revealed five patients with congenital adrenal hyperplasia (CAH) due to partial and combined 21- and 11 beta-hydroxylase deficiency. One patient (A-11 1), a 23-yr-old severely virilized chromosomal female, was reared as a male, and two females (B-11 2 and C-1) complained only of hirsutism, acne, and menstrual abnormalities. Patients A-11 2 and B-11 8 (17 1/2 and 10 yr old) were asymptomatic and detected by finding an HLA genotype identical to that of their respectively affected brother and sister. Three patients (A-11 1, A-11 2, and C-1) had moderate hypertension. In spite of the wide range of clinical manifestations, all individuals had elevated androgen levels, while cortisol secretion was severely impaired only in A-11 2. 21-Hydroxylase deficiency was diagnosed on the basis of markedly increased plasma and urinary levels of 17-hydroxyprogesterone (17-OHP) and 21-deoxycortisol and their respective urinary metabolites pregnanetriol and pregnanetriolone. PRA was elevated in three patients, while urinary aldosterone was normal or increased. 11 beta-Hydroxylase deficiency was diagnosed on the basis of increased 11-deoxycortisol and deoxycorticosterone in plasma and tetrahydro-11-deoxycortisol and deoxycorticosterone in urine, particularly after ACTH administration. In contrast to classical 11 beta-hydroxylase deficiency CAH, urinary 18-hydroxycorticosterone and 18-hydroxy-11-deoxycorticosterone were normal or elevated. The nature and mechanism of a combined enzymatic defect are unknown. The coincidental presence in a single individual of the mutant genes for both 21- and 11 beta-hydroxylase deficiency CAH is very unlikely to occur. Two alternative hypotheses may explain our findings. One is the existence of a genetically inherited abnormal (or aberrant) 11 beta-hydroxylase, whose affinity for its normal substrate is changed for an abnormal one (17-OHP). As a result, 11 beta-hydroxylation of 11-deoxycortisol is deficient while 17-OHP 11 beta-hydroxylation is markedly enhanced. Thus, both 11-deoxycortisol and 21-deoxycortisol as well as their urinary metabolites accumulate. The ability for 18-hydroxylation, however, remains normal. In this case, 21-hydroxylase is not deficient, yet 21-deoxycortisol cannot be further hydroxylated to cortisol, since this steroid is not a suitable substrate for the enzyme. Such a disorder may represent a new allelic variant of 11 beta-hydroxylase deficiency CAH, which, similar to 21-hydroxylase deficiency, is completely linked to the HLA complex.(ABSTRACT TRUNCATED AT 400 WORDS)
authors.forename: A
authors.initials: A
authors.lastname: Hurwitz
authors.forename: C
authors.initials: C
authors.lastname: Brautbar
authors.forename: A
authors.initials: A
authors.lastname: Milwidsky
authors.forename: P
authors.initials: P
authors.lastname: Vecsei
authors.forename: A
authors.initials: A
authors.lastname: Milewicz
authors.forename: D
authors.initials: D
authors.lastname: Navot
authors.forename: A
authors.initials: A
authors.lastname: Rösler
mesh_terms: D000312:Adrenal Hyperplasia, Congenital / Q000201:enzymology* / Q000235:genetics / Q000378:metabolism; D000324:Adrenocorticotropic Hormone; D000328:Adult; D000728:Androgens / Q000097:blood / Q000652:urine; D003907:Dexamethasone; D005260:Female; D005838:Genotype; D005938:Glucocorticoids / Q000097:blood / Q000652:urine; D006680:HLA Antigens / Q000235:genetics; D006801:Humans; D008297:Male; D008901:Mineralocorticoids / Q000097:blood / Q000652:urine; D013250:Steroid Hydroxylases / Q000172:deficiency*
chemical_list: D000728:Androgens; D005938:Glucocorticoids; D006680:HLA Antigens; D008901:Mineralocorticoids; D003907:Dexamethasone; D000324:Adrenocorticotropic Hormone; D013250:Steroid Hydroxylases