title: LC-MS/MS based determination of basal- and ACTH-stimulated plasma concentrations of 11 steroid hormones: implications for detecting heterozygote CYP21A2 mutation carriers.
abstract: OBJECTIVE
  Heterozygosity in 21-hydroxylase deficiency (21OHD) has been associated with hyperandrogenemic symptoms in children and adults. Moreover, the carrier status is mandatory for genetic counseling. We aimed at defining a hormonal parameter for carrier detection by mass spectrometry.
  
  
  METHODS
  Eleven basal and ACTH-stimulated steroid hormones of heterozygous carriers of CYP21A2 mutations and control individuals were compared.
  
  
  METHODS
  Hormones were determined in plasma samples by liquid chromatography tandem mass spectrometry (LC-MS/MS) in 58 carriers (35 males, 23 females, age range 6-78 years) and 44 random controls (25 males, 19 females, age range 8-58 years).
  
  
  RESULTS
  Heterozygotes could be identified best applying the 17-hydroxyprogesterone+21-deoxycortisol/cortisol×1000 ((17OHP+21S)/F×1000) equation 30  min after ACTH injection. An optimal cut-off value of 8.4 provided 89% sensitivity and specificity. Considering this data and a published frequency of heterozygotes of 1/50 to 1/61, the positive predictive value (PPV) of this cut-off is 12%. Of note, the negative predictive value (NPV) excluding heterozygosity in a given patient is 99.8%.
  
  
  CONCLUSIONS
  Considering only marginal biochemical effects anticipated from heterozygosity, the stimulated ((17OHP+21S)/F×1000) identifies and excludes heterozygotes remarkably well. Nevertheless, LC-MS/MS cannot replace genetic testing, since sensitivity and specificity did not reach 100%. However, due to the considerably high NPV of the optimal cut-off and to a specificity of even 100% applying a cut-off higher than 14.7, hormonal assessment of heterozygosity can be of significant aid in conditions with limited access to genetic testing, as in some health care systems. The ((17OHP+21S)/F×1000) equation can guide diagnostic considerations in the differential diagnosis of hyperandrogenism.
authors: Division of Pediatric Endocrinology and DiabetesDepartment of PediatricsInstitute of Medical Informatics and StatisticsUniversity Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schwanenweg 20, D-24105 Kiel, Germany alexandra.kulle@uksh.de.
authors: A E
authors: AE
authors: Kulle
authors: Division of Pediatric Endocrinology and DiabetesDepartment of PediatricsInstitute of Medical Informatics and StatisticsUniversity Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schwanenweg 20, D-24105 Kiel, Germany.
authors: F G
authors: FG
authors: Riepe
authors: Division of Pediatric Endocrinology and DiabetesDepartment of PediatricsInstitute of Medical Informatics and StatisticsUniversity Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schwanenweg 20, D-24105 Kiel, Germany.
authors: J
authors: J
authors: Hedderich
authors: Division of Pediatric Endocrinology and DiabetesDepartment of PediatricsInstitute of Medical Informatics and StatisticsUniversity Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schwanenweg 20, D-24105 Kiel, Germany.
authors: W G
authors: WG
authors: Sippell
authors: Division of Pediatric Endocrinology and DiabetesDepartment of PediatricsInstitute of Medical Informatics and StatisticsUniversity Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schwanenweg 20, D-24105 Kiel, Germany.
authors: J
authors: J
authors: Schmitz
authors: Division of Pediatric Endocrinology and DiabetesDepartment of PediatricsInstitute of Medical Informatics and StatisticsUniversity Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schwanenweg 20, D-24105 Kiel, Germany.
authors: L
authors: L
authors: Niermeyer
authors: Division of Pediatric Endocrinology and DiabetesDepartment of PediatricsInstitute of Medical Informatics and StatisticsUniversity Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schwanenweg 20, D-24105 Kiel, Germany.
authors: P M
authors: PM
authors: Holterhus
mesh_terms: D019326:17-alpha-Hydroxyprogesterone / Q000097:blood; D000293:Adolescent; D000312:Adrenal Hyperplasia, Congenital / Q000097:blood / Q000175:diagnosis* / Q000235:genetics; D000324:Adrenocorticotropic Hormone; D000328:Adult; D000368:Aged; D000735:Androstenedione / Q000097:blood; D016022:Case-Control Studies; D002648:Child; D002853:Chromatography, Liquid; D003345:Corticosterone / Q000097:blood; D003348:Cortisone / Q000097:blood; D003350:Cortodoxone / Q000097:blood; D003900:Desoxycorticosterone / Q000097:blood; D013196:Dihydrotestosterone / Q000097:blood; D005260:Female; D006580:Genetic Carrier Screening / Q000379:methods*; D006728:Hormones; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D008297:Male; D008875:Middle Aged; D011374:Progesterone / Q000097:blood; D013255:Steroid 21-Hydroxylase / Q000235:genetics*; D053719:Tandem Mass Spectrometry; D013739:Testosterone / Q000097:blood; D055815:Young Adult
chemical_list: D006728:Hormones; D013196:Dihydrotestosterone; D013739:Testosterone; D000735:Androstenedione; D003900:Desoxycorticosterone; D011374:Progesterone; C003556:21-deoxycortisol; D019326:17-alpha-Hydroxyprogesterone; D000324:Adrenocorticotropic Hormone; C531510:CYP21A2 protein, human; D013255:Steroid 21-Hydroxylase; D003348:Cortisone; D003345:Corticosterone; D003350:Cortodoxone; D006854:Hydrocortisone