21-hydroxylase deficiency differential diagnosis: Difference between revisions

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{{21-hydroxylase deficiency}}
{{21-hydroxylase deficiency}}
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{| class="wikitable"
{| class="wikitable"
!Disease name
!Disease name
!Steroid status
! colspan="2" |Laboratory tests
!Other laboratory
!Important clinical findings
!Important clinical findings
|-
!
!Increased
!Decreased
!
|-
|-
|Classic type of 21-hydroxylase deficiency
|Classic type of 21-hydroxylase deficiency
|Increased:
|
* 17-OHP  
* 17-OHP  
* Progesterone
* Progesterone
* Androstenedione
* Androstenedione
* DHEA
* DHEA
Decreased:
|
* Aldosterone
* Aldosterone
* Corticosterone (salt-wasting)
* Corticosterone (salt-wasting)
* Cortisol (simple virilizing)
* Cortisol (simple virilizing)
|
*Low testosterone levels
|
|
* Ambigus genitalia in female
* Ambigus genitalia in female
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|-
|-
|[[Congenital adrenal hyperplasia due to 11β-hydroxylase deficiency|11-β hydroxylase deficiency]]
|[[Congenital adrenal hyperplasia due to 11β-hydroxylase deficiency|11-β hydroxylase deficiency]]
|Increased:
|
* DOC
* DOC
* 11-Deoxy-cortisol
* 11-Deoxy-cortisol
* 17-hydroxy-progestrone, mild elevation
* 17-hydroxy-progestrone, mild elevation
Decreased:
|
* Cortisol
* Cortisol
* Corticosterone
* Corticosterone
* Aldosterone  
* Aldosterone
|
* Low testosterone levels
|
|
* Ambigus genitalia in female
* Ambigus genitalia in female
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|-
|-
|[[Congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency|17-α hydroxylase deficiency]]
|[[Congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency|17-α hydroxylase deficiency]]
|Increased:
|
* DOC
* DOC
* Corticosterone
* Corticosterone
* Progesterone
* Progesterone
Decreased:
|
*Cortisol
* Cortisol
* Aldosterone
* Aldosterone
|
* Low testosterone levels
* Not elevated any type of androgens
|
|
* Ambigus genitalia in male
* Ambigus genitalia in male
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|-
|-
|3β-Hydroxysteroid Dehydrogenase  
|3β-Hydroxysteroid Dehydrogenase  
|Increased:
|
* DHEA
* DHEA
* 17-OH pregneno-lone  
* 17-OH pregneno-lone  
* Pregnenolone
* Pregnenolone
Decreased:
|
* Cortisol
* Cortisol
* Aldosterone
* Aldosterone
|
* Low testosterone levels
|
|
* Vomiting, volume depletion, hyponatremia, and hyperkalemia
* Vomiting, volume depletion, hyponatremia, and hyperkalemia
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* Maternal serum androgen concentrations (usually testosterone and androstenedione) are high  
* Maternal serum androgen concentrations (usually testosterone and androstenedione) are high  
* If virilization is caused by exogenous hormone administration, the values may be low because the offending hormone is usually a synthetic steroid not measured in assays for testosterone or other androgens
* If virilization is caused by exogenous hormone administration, the values may be low because the offending hormone is usually a synthetic steroid not measured in assays for testosterone or other androgens
 
|
|
|
* Androgen excess sign and symptoms in mother
* Androgen excess sign and symptoms in mother
* History of androgen containing medication  consumption during pregnancy in mother
* History of androgen containing medication  consumption during pregnancy in mother
* Virilization in a 46,XX individual with normal female internal anatomy  
* Virilization in a 46,XX individual with normal female internal anatomy
* Causes include maternal luteoma or theca-lutein cysts, and placental aromatase enzyme deficiency
* Causes include maternal luteoma or theca-lutein cysts, and placental aromatase enzyme deficiency
|}
|}


[[Congenital adrenal hyperplasia]] due to 21-hydroxylase deficiency Non-classic type must be differentiated from diseases that cause virilization and hirsutism in female:<ref name="pmid24830586">{{cite journal |vauthors=Hohl A, Ronsoni MF, Oliveira Md |title=Hirsutism: diagnosis and treatment |journal=Arq Bras Endocrinol Metabol |volume=58 |issue=2 |pages=97–107 |year=2014 |pmid=24830586 |doi= |url=}}</ref><ref name="pmid10857554">{{cite journal |vauthors=White PC, Speiser PW |title=Congenital adrenal hyperplasia due to 21-hydroxylase deficiency |journal=Endocr. Rev. |volume=21 |issue=3 |pages=245–91 |year=2000 |pmid=10857554 |doi=10.1210/edrv.21.3.0398 |url=}}</ref><ref name="ISBN:978-0323297387">{{cite book | last = Melmed | first = Shlomo | title = Williams textbook of endocrinology | publisher = Elsevier | location = Philadelphia, PA | year = 2016 | isbn = 978-0323297387 }}=</ref>
[[21-hydroxylase deficiency]] Non-classic type must be differentiated from diseases that cause [[virilization]] and [[hirsutism]] in female:<ref name="pmid24830586">{{cite journal |vauthors=Hohl A, Ronsoni MF, Oliveira Md |title=Hirsutism: diagnosis and treatment |journal=Arq Bras Endocrinol Metabol |volume=58 |issue=2 |pages=97–107 |year=2014 |pmid=24830586 |doi= |url=}}</ref><ref name="pmid10857554">{{cite journal |vauthors=White PC, Speiser PW |title=Congenital adrenal hyperplasia due to 21-hydroxylase deficiency |journal=Endocr. Rev. |volume=21 |issue=3 |pages=245–91 |year=2000 |pmid=10857554 |doi=10.1210/edrv.21.3.0398 |url=}}</ref><ref name="ISBN:978-0323297387">{{cite book | last = Melmed | first = Shlomo | title = Williams textbook of endocrinology | publisher = Elsevier | location = Philadelphia, PA | year = 2016 | isbn = 978-0323297387 }}=</ref>


{| class="wikitable"
{| class="wikitable"
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* Exaggerated androstene-dione, DHEA, and 17-OHP  
* Exaggerated androstene-dione, DHEA, and 17-OHP  
response to ACTH  
response to ACTH  
|Low testosterone levels
|
* Low testosterone levels
|
|
* No symptoms in infancy and male
* No symptoms in infancy and male


* virilization in females
* Virilization in females
|-
|-
|[[Congenital adrenal hyperplasia due to 11β-hydroxylase deficiency|11-β hydroxylase deficiency]]
|[[Congenital adrenal hyperplasia due to 11β-hydroxylase deficiency|11-β hydroxylase deficiency]]
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* Corticosterone
* Corticosterone
* Aldosterone  
* Aldosterone  
|Low testosterone levels
|
* Low testosterone levels
|
|
* Hypertension and hypokalemia
* Hypertension and hypokalemia
* Virilization
* Virilization
|-
|[[Congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency|17-α hydroxylase deficiency]]
|Increased:
* DOC
* Corticosterone
* Progesterone
Decreased:
*Cortisol
* Aldosterone
|Low testosterone levels
|
* Hypertension
* Primary amenorrhea
* Absence of secondary sexual characteristics
* Minimal body hair
|-
|-
|3β-Hydroxysteroid Dehydrogenase  
|3β-Hydroxysteroid Dehydrogenase  
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* Cortisol
* Cortisol
* Aldosterone
* Aldosterone
|Low testosterone levels
|
* Low testosterone levels
|
|
* Salt-wasting adrenal crises in infancy
* Salt-wasting adrenal crises in infancy
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|
|
* Infertility, galactorrea  
* Infertility, galactorrea  
|-
|}
|}


== References ==
== References ==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 16:15, 26 July 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Mehrian Jafarizade, M.D [2]

Overview

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency must be differentiated from 11-β hydroxylase deficiency, 17-α hydroxylase deficiency, androgen insensitivity syndrome, 3β-Hydroxysteroid Dehydrogenase, polycystic ovarian syndrome, hyperprolactinemia, cushing syndrome, and adrenal tumor.

Differentiating congenital adrenal hyperplasia due to 21-hydroxylase deficiency from other diseases

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency classic type must be differentiated from diseases that cause ambiguous genitalia:[1][2]

Disease name Laboratory tests Important clinical findings
Increased Decreased
Classic type of 21-hydroxylase deficiency
  • 17-OHP
  • Progesterone
  • Androstenedione
  • DHEA
  • Aldosterone
  • Corticosterone (salt-wasting)
  • Cortisol (simple virilizing)
  • Ambigus genitalia in female
  • Virilization in female
  • Salt-wasting
  • Hypotension and hyperkalemia
11-β hydroxylase deficiency
  • DOC
  • 11-Deoxy-cortisol
  • 17-hydroxy-progestrone, mild elevation
  • Cortisol
  • Corticosterone
  • Aldosterone
  • Ambigus genitalia in female
  • Hypertension and hypokalemia
  • Virilization
17-α hydroxylase deficiency
  • DOC
  • Corticosterone
  • Progesterone
  • Cortisol
  • Aldosterone
  • Ambigus genitalia in male
  • Hypertension
  • Primary amenorrhea
  • Absence of secondary sexual characteristics
  • Minimal body hair
3β-Hydroxysteroid Dehydrogenase
  • DHEA
  • 17-OH pregneno-lone
  • Pregnenolone
  • Cortisol
  • Aldosterone
  • Vomiting, volume depletion, hyponatremia, and hyperkalemia
  • 46-XY infants often show undervirilization, due to a block in testosterone synthesis
Gestational hyperandrogenism
  • Maternal serum androgen concentrations (usually testosterone and androstenedione) are high
  • If virilization is caused by exogenous hormone administration, the values may be low because the offending hormone is usually a synthetic steroid not measured in assays for testosterone or other androgens
  • Androgen excess sign and symptoms in mother
  • History of androgen containing medication consumption during pregnancy in mother
  • Virilization in a 46,XX individual with normal female internal anatomy
  • Causes include maternal luteoma or theca-lutein cysts, and placental aromatase enzyme deficiency

21-hydroxylase deficiency Non-classic type must be differentiated from diseases that cause virilization and hirsutism in female:[3][2][4]

Disease name Steroid status Other laboratory Important clinical findings
Non-classic type of 21-hydroxylase deficiency Increased:
  • 17-OHP
  • Exaggerated androstene-dione, DHEA, and 17-OHP

response to ACTH

  • Low testosterone levels
  • No symptoms in infancy and male
  • Virilization in females
11-β hydroxylase deficiency Increased:
  • DOC
  • 11-Deoxy-
  • cortisol

Decreased:

  • Cortisol
  • Corticosterone
  • Aldosterone
  • Low testosterone levels
  • Hypertension and hypokalemia
  • Virilization
3β-Hydroxysteroid Dehydrogenase Increased:
  • DHEA
  • 17-OH pregneno-lone
  • Pregnenolone

Decreased:

  • Cortisol
  • Aldosterone
  • Low testosterone levels
  • Salt-wasting adrenal crises in infancy
  • Mild virilization of genetically female infants
  • Undervirilization of genetically male infants, making it the only form of CAH which can cause ambiguous genitalia in both genetic sexes.
Polycystic ovary syndrome
  • High DHEAS and androstenedione levels
  • Low testosterone levels
  • Polycystic ovaries in sonography
  • Obesity
  • PCOS is the most common cause of hirsutism in women
  • No evidence another diagnosis
Adrenal tumors
  • Variable levels depends on tumor type
  • Low testosterone level
  • Older age
  • Rapidly progressive symptoms
Ovarian virilizing tumor
  • Variable levels depends on tumor type
  • Testosterone is high
  • Older age
  • Rapidly progressive symptoms
Cushing's syndrome
  • Increase cortisol & metabolites
  • Variable other steroids
  • Variable mineralocorticoid excess
  • Cushingoid features
Hyperprolactinemia
  • Normal levels of most of steroids
  • Increased prolactin
  • Infertility, galactorrea

References

  1. Hughes IA, Nihoul-Fékété C, Thomas B, Cohen-Kettenis PT (2007). "Consequences of the ESPE/LWPES guidelines for diagnosis and treatment of disorders of sex development". Best Pract. Res. Clin. Endocrinol. Metab. 21 (3): 351–65. doi:10.1016/j.beem.2007.06.003. PMID 17875484.
  2. 2.0 2.1 White PC, Speiser PW (2000). "Congenital adrenal hyperplasia due to 21-hydroxylase deficiency". Endocr. Rev. 21 (3): 245–91. doi:10.1210/edrv.21.3.0398. PMID 10857554.
  3. Hohl A, Ronsoni MF, Oliveira M (2014). "Hirsutism: diagnosis and treatment". Arq Bras Endocrinol Metabol. 58 (2): 97–107. PMID 24830586. Vancouver style error: initials (help)
  4. Melmed, Shlomo (2016). Williams textbook of endocrinology. Philadelphia, PA: Elsevier. ISBN 978-0323297387.=