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Severe Combined Adrenal and Gonadal Deficiency Caused by Novel Mutations in the Cholesterol Side Chain Cleavage Enzyme, P450scc

Department of Pediatrics (C.J.K., N.H., W.L.M.), University of California, San Francisco, California 94143; UCL Institute of Child Health (L.L., J.C.A.), University College London, London WC1N 1EH, United Kingdom; Lilly Research Laboratories (C.A.Q.), US Medical, Indianapolis, Indiana 46285; and Division of Pediatric Endocrinology and Metabolism (T.W.A.), The Brookdale University Hospital and Medical Center, State University of New York, Brooklyn, New York 11212

Address all correspondence and requests for reprints to: Professor Walter L. Miller, Department of Pediatrics, University of California San Francisco, San Francisco, California 94143-0978, E-mail: wlmlab{at}ucsf.edu; or Dr. John C. Achermann, Developmental Endocrinology Research Group, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom. E-mail: j.achermann{at}ich.ucl.ac.uk.

Context: Mitochondrial cytochrome P450scc converts cholesterol to pregnenolone in all steroidogenic tissues. Although progesterone production from the fetally-derived placenta is necessary to maintain pregnancy to term, four patients with mutations in the gene encoding P450scc (CYP11A1), have been described, one in a 46,XX female and three in underandrogenized 46,XY individuals, all with primary adrenal failure.

Objective: Our aim was to determine whether P450scc mutations might be found in other children and to explore genotype/phenotype correlations.

Methods and Patients: We performed mutational analysis of CYP11A1 in individuals with 46,XY disorders of sex development and primary adrenal failure, followed by functional studies of P450scc activity and of P450scc RNA splicing.

Results: Among nine 46,XY infants with adrenal failure and disordered sexual differentiation, two infants had compound heterozygous mutations in CYP11A1. One patient harbored the novel P450scc missense mutations L141W and V415E, which retained 38 and 0% activity, respectively. The other carried a CYP11A1 frameshift mutation c835delA (0% activity) and a splice site mutation [IVS3+(2-3)insT] that prevented correct splicing of P450scc mRNA.

Conclusions: P450scc deficiency is a recently recognized disorder that may be more frequent than originally thought. The phenotypic spectrum ranges from severe loss-of-function mutations associated with prematurity, complete underandrogenization, and severe, early-onset adrenal failure, to partial deficiencies found in children born at term with clitoromegaly and later-onset adrenal failure. In contradistinction to congenital lipoid adrenal hyperplasia caused by steroidogenic acute regulatory protein mutations, adrenal hyperplasia has not been reported in any of the six patients with P450scc deficiency.

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