OBJECTIVE

To report one case of isosexual precocious pseudopuberty in a 4-year-old boy caused by an interstitial cell testicular tumor.

METHODS

Physical exam, blood tests, hormonal determinations, adrenal suppression tests, bone age, orchiectomy and pathologic study of the specimen were performed.

RESULTS

Physical examination showed a boy with muscle development, acne; body, sexual and face hair corresponding to an older boy; with increased volume of the left testicle and infantile contralateral testicle. Urinary <em>17</em>-<em>ketosteroids</em> were elevated and did not decrease after dexametasone. Bone age corresponded to an 11-year-old standard. Pathologic study showed an interstitial cell tumor. Puberty changes disappeared after orchiectomy.

CONCLUSIONS

This diagnosis should be taken into consideration in every case of accelerated sexual development in a boy with testicular tumor and without maturation of the contralateral testicle.

Extensive hormonal evaluation was performed in a girl with adrenal carcinoma during the primary tumor stage, following adrenalectomy, during the period when metastases were evident and while on treatment with o,p'-DDD. At the age of 14 months a diagnosis of congenital adrenal hyperplasia was made and treatment with dexamethasone (0.125 to 0.25 mg/day) resulted in a fall-off in growth rate, normal advancement in bone age, decrease in virilization and suppression of <em>17</em>- <em>ketosteroid</em> excretion which continued until 4 3/12 years of age when virilization increased. At five years of age elevated serum and urinary androgen levels unsuppressible with dexamethasone were noted. Following removal of a large right adrenal carcinoma, serum and urinary hormone levels returned to normal. There months following surgery, liver metastases were documented associated with elevated levels of serum androgens. With o,p'-DDD treatment, serum dehydroepiandrosterone sulfate (DS) and urinary <em>17</em>-<em>ketosteroid</em> (<em>17</em>-KS) excretion fell rapidly while there was a delay in the fall of free androgens. The persistence of free steroid secretion with decreased formation of DS suggests that the o,p'-DDD may have altered sulfatase activity before causing tumor necrosis and total decrease in steroidogenesis.

Adrenocortical carcinoma (ACC) is a rare disorder with an estimated incidence of only 0.023 percent of all malignancies. In most cases, Cushing's syndrome and virilization or feminization due to abnormal steroid production by the tumor rapidly lead to the diagnosis. Occasionally, the tumor produces an excessive amount of mineralocorticoids only and ACC can be revealed by an isolated syndrome of primary aldosteronism. Out of 100 cases of tumoral primary aldosteronism studied from 1977 to 1987, we observed 4 ACC and 96 Conn's adenomas (CONN). When primary aldosteronism was diagnosed, ACC and CONN had same clinical features, although hypokalemia in ACC was more profound: 2.2 +/- 0.76 mmol/l (1.4 to 3.2) compared to 2.9 +/- 0.5 (1.6 to 4.2) in CONN. Mean supine plasma aldosterone levels, plasma renin and aldosterone responses to the upright posture or to serum saline infusion, cortisol at 8 a.m. were not different in patients with ACC from those observed in patients with CONN. 24 hours urinary cortisol excretion and <em>17</em>-<em>ketosteroids</em> excretion were highly increased in three out four patients with ACC. Clinical, biological and hormonal investigations were therefore not sufficient to diagnose malignant tumoral primary aldosteronism. Systematic computed tomographic scanning allowed to differentiate carcinomas from adenomas on the following criteria: ACC showed enlarged tumor size that was always above 30 mm in diameter, whereas the largest CONN measured 20 mm.ACC appeared as an heterogeneous tumor with the presence of internal calcifications in each case of ACC, that were diagnosed both on ultrasound and CT scan, whereas none of the CONN showed any calcification, using the same screening procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

A 3-year-old girl affected by a virilizing tumor of the adrenal gland, without significant elevation in the levels of <em>17</em> <em>ketosteroids</em> (<em>17</em>-KS) urinary excretion, was studied clinically. Her symptoms started abruptyly at the age of 2, with progressive enlargement of the clitoris and the appearance of pubic hair. In various tests, the <em>17</em>-KS levels barely exceeded the upper normal limits and at times remained within normal limits. The retropneumoperitoneum X-ray suggested an enlargement of the right adrenal gland and the presence of a neoplasm, which was actually discovered during surgery. Histopathological examination revealed a well-defined neoplasm, without capsule invasion and with accentuated cell polymorphism. Histoenzymology showed that the tissue lacked the enzymatic system involving 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD). Indoxylesterase (I.EST-A) activity identified the tumor as originating from the internal layers of the adrenal cortex. The histochemical findings were correlated to the clinical picture and the levels of urinary <em>17</em>-KS.

A 53-year-old woman experienced progressive general weakness and lumbago in the 2 years prior to a physical examination which disclosed cushingoid manifestations and a skin ulcer on the back of her right knee joint. Her plasma cortisol concentration ranged from 24.7 to 31.1 microg/dl, with an ACTH level <5 pg/ml. Urinary excretions of <em>17</em>-hydroxycorticosteroid (<em>17</em>-OHCS) and <em>17</em>-<em>ketosteroid</em> (<em>17</em>-KS) were 20.5 mg/day and 5.1 mg/day, respectively, and urinary cortisol was also increased (421 microg/day). Cortisol was not suppressed after the administration of 8 mg dexamethasone. Abdominal ultrasound sonography, computed tomography (CT) scan, and magnetic resonance imaging (MRI) studies demonstrated a left adrenal tumor and further, a chest X-ray examination showed a cavitary lesion containing a fungus ball-like mass in the left lower lung field. The serum cryptococcal antigen titer was positive at 1:128 and a bronchoalveolar lavage fluid culture yielded a growth of Cryptococcus neoformans. A biopsy specimen of the skin ulcer also suggested cryptococcosis. As a result, a left adrenectomy was performed, and the excised specimen was shown to be an adenoma consisting of compact cells with abundant pigmentation (black adenoma). A diagnosis of functioning black adenoma of the adrenal gland, complicated with pulmonary and cutaneous cryptococcosis was made.

A case of advanced cervical carcinoma of the uterus with ectopic adrenocorticotrophic hormone (ACTH) syndrome is described. The patient was seen for general malaise 21 months after surgical treatment of the primary lesion whose histology was undifferentiated small cell carcinoma of the uterine cervix. She had extensive metastases in the liver and the abdominal wall. In addition to the typical clinical manifestations of Cushing's syndrome such as moon face, central obesity and acne vulgaris, hyperglycemia was so severe that she was in a hyperosmolar non-ketotic coma. Endocrinological examinations revealed elevated plasma ACTH and cortisol, and urinary excretion of <em>17</em>-hydroxycorticosteroids and <em>17</em>-<em>ketosteroids</em>, which were not suppressed by high-dose dexamethasone administration. Based on these clinical and laboratory findings, a diagnosis of ectopic ACTH syndrome was made. Among the results of other endocrinological examinations conducted to find the etiological cause of the hyperglycemic coma, which seemed to be unusual for ectopic ACTH syndrome, the plasma somatostatin level was abnormally high. Metastatic tumors in the liver obtained at the time of autopsy contained large amounts of both ACTH and somatostatin, and gel filtration studies revealed that the peptides produced by the tumor had the molecular sizes of the biologically active forms of the respective peptides. These observations suggest possible involvement of the somatostatin in deteriorating glucose intolerance to develop hyperglycemic hyperosmolar non-ketotic coma as a drastic disturbance of metabolism.

The lipoidal derivatives of [3H]pregnenolone, prepared biosynthetically, were converted, by incubation with a mitochondrial-microsomal fraction from adrenal cortical tissue, into lipoidal derivatives of <em>17</em>-hydroxy-pregnenolone and of dehydroisoandrosterone, thus proving that these pregnenolone derivatives can serve as substrates for <em>17</em>-hydroxylase and for the lyase enzyme that converts a C21-<em>17</em>-hydroxy-20-ketol into a C19-<em>17</em>-<em>ketosteroid</em>. Three synthetically prepared esters of pregnenolone, the oleate, the linoleate, and the arachidonate, were also hydroxylated at C-<em>17</em> by a similar adrenal preparation. With the synthetic substrates, however, the corresponding esters of dehydroisoandrosterone were not formed.

The clinical features, ovarian pathology, and hormonal responses to dexamethasone (Dex), Dex + ethinyl estradiol (EE), and Dex + hCG were compared in 5 women with polycystic ovarian disease (PCOD) who have normal 24-hr urinary luteinizing hormone (LH levels to 5 who had elevated urinary LH levels. No differences were noted in the clinical features. There was no correlation between ovary size and LH levels. Three in the normal-LH group had hyperthecosis. Plasma androstenedione (A) was more frequently elevated in the high-LH group. Dex + EE markedly increased LH secretion in the high-LH group, suggesting increased responsiveness of the positive feedback control mechanism of LH secretion in the high-LH group. There was a greater response of A, testosterone (T), and <em>17</em>-<em>ketosteroids</em> to Dex + hCG in the normal-LH group. Those with high-LH levels did not exhibit a significant increase in A, T, and <em>17</em>-KS with hCG. The limitations and usefulness of the Dex + hCG test are discussed. The hypothesis is advanced that the increased LH secretion in the high-LH group is due at least in part to positive feedback resulting from the increased A levels. The amount of <em>17</em>beta-oxidoreductase activity in the ovary may influence LH secretion in PCOD.

Expression of the human Ke 6 gene, <em>17</em>beta-hydroxysteroid dehydrogenase type 8, in E. coli and the substrate specificity of the expressed protein were examined. The tissue distribution of mRNA expression of the human Ke 6 gene was also studied using real-time PCR. Human Ke 6 gene was expressed as an enzymatically-active His-tag fusion protein, whose molecular weight was estimated to be 32.5 kDa by SDS-polyacrylamide gel electrophoresis. Expressed human Ke 6 gene effectively catalyzed the conversion of estradiol into estrone. Testosterone, 5alpha-dihydrotestosterone, and 5-androstene-3beta,<em>17</em>beta-diol were also catalyzed into the corresponding <em>17</em>-<em>ketosteroid</em> at 2.4-5.9% that of estradiol oxidation. Furthermore, expressed enzyme catalyzed the reduction of estrone to estradiol, but the rate was a mere 2.3%. Human Ke 6 gene mRNA was expressed in the various tissues examined, such as brain, cerebellum, heart, lung, kidney, liver, small intestine, ovary, testis, adrenals, placenta, prostate, and stomach. Expression of human Ke 6 gene mRNA was especially abundant in prostate, placenta, and kidney. The levels in prostate and placenta were higher than that in kidney, where it is known to be expressed in large quantities.

RU-486 is a synthetic steroid analogue that can inhibit adrenal steroid synthesis in the rat and rhesus monkey. We measured the activities of five testicular and two ovarian microsomal steroidogenic enzymes to assess the potential effect of RU-486 on rat gonadal steroidogenesis. Hypophysectomized, gonadotropin-replaced rats received RU-486 or a vehicle solution twice daily for seven days. The animals were sacrificed and their gonads were resected, weighed, and microsomal enzyme activities were measured according to RU-486 treatment. Testicular <em>17</em>-hydroxylase and aromatase activity decreased in RU-486 treated animals whereas <em>17</em>,20-desmolase, 3 beta-hydroxysteroid dehydrogenase and <em>17</em>-<em>ketosteroid</em> reductase activities were unaffected. Ovarian <em>17</em>-hydroxylase but not 3 beta-hydroxysteroid dehydrogenase activity was decreased in the animals receiving the drug. We conclude that RU-486 inhibits both testicular and ovarian steroidogenesis in the rat.

Eleven cases of true hermaphroditism (eight previously reported) studied at The Johns Hopkins Hospital are presented. The two most recently observed patients had what is to be considered an appropriate endocrine evaluation. This includes karyotyping, and measurement of 24-hour urinary <em>17</em>-<em>ketosteroids</em>, gonadotropins, plasma testosterone, dihydrotestosterone, and all their precursors before and following a human chorionic gonadotropin stimulation test, and a sexual skin biopsy for androgen receptor binding and 5 alpha-reductase activity. The differential diagnosis of true hermaphroditism is discussed and an approach to gender assignment is presented.

Whole cells and crude extract of Mycobacterium sp. VKM Ac-1815D mutant strain Et1 were shown to carry out <em>17</em>beta-reduction, <em>17</em>beta-dehydrogenation and 1(2)-reduction of 3-keto-C(19)-steroids. Two <em>17</em>-hydroxy steroid dehydrogenases (<em>17</em>-OH SDH) were partially purified from the strain by ammonium sulfate fractionation, ion-exchange chromatography on DEAE-sephacel and gel-filtration on Bio-Gel A. The enzymes differed in chromatographic properties and specific activities. One enzyme--<em>17</em>-OH SDH (2) (tetramer, M(r) approximately 210,000) was found to be responsible for bi-directional reduction-oxidation of steroids at C <em>17</em>, whereas the other one--<em>17</em>-OH SDH (1) (monomer, M(r) approximately 68,000) specifically catalysed <em>17</em>beta-dehydrogenation of <em>17</em>-hydroxysteroids (testosterone and 1(2)-dehydro testosterone). The <em>17</em>beta-reduction of 1-ene-<em>17</em>-<em>ketosteroids</em> was accompanied by 1(2)-reduction. A role of 1-ene-reductase as a steroid-binding protein associated with <em>17</em>-OH SDH (2) in Mycobacterium sp. is discussed.

We treated 5 patients with Cushing's disease by total adrenalectomy and left adrenal autotransplantation with attached blood vessels. An end-to-end vascular anastomosis was made between the adrenal central vein and the inferior epigastric artery, and the saphenous vein and adrenal middle artery were anastomosed by intussuscepting the artery into the vein in 4 patients. Steroid replacement was withdrawn 7 to 90 days after bilateral total adrenalectomy. The patients were followed for 1 to 4 years. Repeated measurement of plasma cortisol, 24-hour urinary <em>17</em>-hydroxycorticosteroid and <em>17</em>-<em>ketosteroid</em> levels in all cases was normal. As soon as the adrenal central vein and inferior epigastric artery were anastomosed part of the adrenal gland was then excised. Oozing of blood from the cut surface was retained and the adrenal gland was then embedded into the inguinal muscle in 1 patient. Small doses of steroid replacement (12.5 mg. cortisone per day) were still necessary 1 year postoperatively. The result thus indicates that this procedure is feasible and valuable for the treatment of patients with Cushing's disease and no evidence of pituitary adenoma on magnetic resonance imaging or computerized tomography.

Studies with animals indicate that there are cyclical changes in the monoamine oxidase (MAO) activity of brain and uterus, and that these changes may be due to changes in estrogen and progesterone levels. To determine if oral contraceptives (OC) alter the tissue MAO activity of healthy women, we measured platelet MAO activity in 7 control women and in 7 women who were receiving combination estrogen-progesterone OC. The platelet MAO of the control women and the women receiving OC did not differ with the use of tryptamine and serotonin as MAO substrates. The two groups did not differ with respect to the following: serum serotonin, plasma tryptophan, plasma tyrosine, and the urinary excretion of tryptamine, tyramine, serotonin, 5-hydroxyindoleacetic acid, creatinine, <em>17</em>-hydroxycorticosteroids, <em>17</em>-<em>ketosteroids</em>, and urinary free cortisol. The subjects receiving OC had higher plasma cortisol concentrations than the controls. Two women in the seventh month of uncomplicated pregnancy, who underwent these studies, had higher plasma cortisol and urinary <em>17</em>-<em>ketosteroid</em> excretion than control subjects. In the remaining tests the results of pregnant subjects did not differ from those of control subjects. We conclude that tissue MAO activity is not altered by OC or pregnancy.

11 beta-hydroxyprogesterone (HOP) and 11-ketoprogesterone (KP) are reversible components of a shuttle pair whose interconversion in rat liver is catalyzed by isoform-1 of 11 beta-hydroxysteroid dehydrogenase. Kidneys also produce this interconversion. The present study was carried out to investigate the shuttle pair and its components in the rat. As in corticosterone/11-dehydrocorticosterone, oxidation is more effective at an alkaline pH, while reduction prevails at a neutral pH. Moreover, both reactions are inhibited by the detergent 3-[(3-cholamido propyl)-dimethylammonio]-1-propane-sulphonate (CHAPS). However, at variance with the 11-<em>ketosteroids</em> cortisone (E) and 11-dehydrocorticosterone (A) thought to be "inactive," KP has slight direct Na(+)-retaining properties, and it, as well as HOP, induces glucocorticoids (11 beta-hydroxycorticoids) to retain sodium. 11-ketoprogesterone exhibits <em>17</em> times better affinity for native type 1 mineralocorticoid receptor than HOP and a 3-fold affinity for partially purified (transcortin free) mineralocorticoid receptor. However, KP, in contrast to HOP, binds only weakly to transcortin, not at all to glucocorticoid receptor, and requires reduction at C11 for tyrosine aminotransferase (TAT) induction.

Adrenomyelodystrophy (AMD), a variant of adrenoleukodystrophy, is associated with both neurologic and adrenal dysfunction. Data from an endocrinologic evaluation of a 41-year-old pigmented white man with AMD showed elevation in basal plasma ACTH, 11-deoxycortisol, <em>17</em>-alpha OH-progesterone and progesterone concentrations, and low normal plasma cortisol levels. Free urinary cortisol and <em>17</em>-<em>ketosteroid</em> secretion values were within normal limits. These data suggest that the principal adrenal enzymatic defect in this patient was a partial block of 11-hydroxylase and that the elevation of precursors was ACTH-dependent. However, this patient may have other enzymatic defects.

The practicability and tolerability of trilostane, a competitive inhibitor of 3 beta-hydroxysteroid-delta 5-dehydrogenase, for the therapy of primary aldosteronism was assessed in 1 patient with aldosterone-producing adenoma (APA) and 3 subjects with idiopathic adrenal hyperplasia (IHA). Trilostane afforded reduction of plasma levels of aldosterone, progesterone, deoxycorticosterone, <em>17</em>-OH progesterone, cortisol, delta 4-androstenedione, and urinary excretion of <em>17</em>-hydroxycorticosteroid. Conversely, circulating levels of dehydroepiandrosterone, dehydroepiandrosterone sulfate, and urinary excretion of <em>17</em>-<em>ketosteroids</em> were increased following this drug therapy. Suppression of mineralo- or glucocorticoid biosynthesis was accompanied by an increase in plasma renin activity. One patient with APA or 3 subjects with IHA showed slight or remarkable improvement of hypertension and hypokalemia. Based on these findings, efficacy and tolerability of trilostane appear to aid in the treatment of IHA.

To investigate whether hyperprolactinemia directly affects rat testicular steroidogenesis, we examined the effects of prolactin (PRL) on microsomal 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD) <em>17</em>-hydroxylase (<em>17</em>-OH), <em>17</em>,20-desmolase (<em>17</em>,20-D), <em>17</em>-<em>ketosteroid</em> reductase (<em>17</em>-KSR) and aromatase enzyme activities. Adult hypophysectomized, gonadotropin-treated Fisher rats were rendered hyperprolactinemic by isografting pituitaries under the kidney capsule. The controls received skeletal muscle. All rats were sacrificed 7 days later and serum PRL was measured in each animal. PRL levels were 198 +/- 14 ng/ml in the hyperprolactinemic rats and 4.3 +/- 0.6 ng/ml in the controls (P less than 0.001). The testes were resected, pooled according to PRL levels, and microsomes were prepared from each pool. The activities of the 3 beta-HSD, <em>17</em>-OH, <em>17</em>,20-D, <em>17</em>-KSR and aromatase were measured using as substrates 14C dehydroepiandrosterone, progesterone, <em>17</em>-hydroxyprogesterone, androstenedione and testosterone, respectively. Hyperprolactinemia was associated with significant decreases in 3 beta-HSD, <em>17</em>-OH, <em>17</em>,20-D, <em>17</em>-KSR and aromatase activities when compared to controls (P less than 0.005). We conclude that prolactin may have a direct effect on rat testicular steroidogenesis which appears to be independent of changes in gonadotropin secretion.

In a middle-aged woman with virilizing adenoma, 2 mg dexamethasone increased urinary excretion of <em>17</em>-<em>ketosteroids</em> (<em>17</em>-KS) and <em>17</em>-hydroxycorticosteroids, whereas 8 mg dexamethasone increased urinary excretion only of <em>17</em>-KS. With discontinuation of dexamethasone, <em>17</em>-KS excretion returned to the predexamethasone level. Dexamethasone depressed the basal level of cAMP synthesis and basal testosterone production by the normal adrenal tissue in vitro. Dexamethasone also depressed the increase of cAMP produced by ACTH in the normal tissue. In contrast, dexamethasone increased basal cAMP synthesis and stimulated testosterone secretion in the tumor tissue. ACTH and dexamethasone were additive in their effects on cAMP and testosterone in the tumor tissue. It is suggested that dexamethasone acted directly on the adrenal tumor to stimulate steroid secretion in this patients.

The case of a 14-year-old girl with hirsutism and virilism due to the secretion of ectopic ACTH by an adrenal medullary tumor is described. At the age of 5 years changes in appearance had begun with masculinization. The effect of ACTH-like material, measured by radioimmunoassay in plasma and in tumor tissue, was compensated partially by the hypothalamo-pituitary-adrenal feedback mechanism. Increased concentrations of dehydroepiandrosterone, estrone and testosterone in plasma and of <em>17</em>-<em>ketosteroids</em> and free cortisol in urine originated in the adrenals. After operation of the tumor menarche began spontaneously, hirsutism disappeared and testosterone plasma concentrations returned to normal. An adrenogenital syndrome was excluded.