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Medical Research Council Human Reproductive Sciences Unit, Center for Reproductive Biology, University of Edinburgh (P.B., G.A.S., J.T., R.A.L.B., P.T.K.S., R.A.A.); and Endocrinology Unit, Molecular Medicine Center, Western General Hospital (J.R.S.), Edinburgh, United Kingdom EH16 4SB
Address all correspondence and requests for reprints to: Dr. Richard A. Anderson, Medical Research Council Human Reproductive Sciences Unit, Center for Reproductive Biology, University of Edinburgh Chancellor’s Building, 49 Little France Crescent, Edinburgh, United Kingdom EH16 4SB. E-mail: r.a.anderson{at}hrsu.mrc.ac.uk.
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Abstract |
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Introduction |
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DAX-1 was assigned to the nuclear receptor superfamily of ligand-activated transcription factors because it contains a region within the C-terminus of the protein with sequence similarities to the ligand-binding domain of other superfamily members (1, 9). The protein contains a unique amino-terminal domain containing 3.5 repeats of a 65- to 67-amino acid motif that forms 2 putative zinc finger domains, although this region is unlike the central DNA-binding domain found in other nuclear receptors (1, 10). To date no ligand for DAX-1 has been identified. DAX-1 has been shown to act as a transcriptional repressor. In particular, there is overwhelming evidence for a coregulatory molecular interaction of DAX-1 with steroidogenic factor-1 (SF-1). SF-1 is essential for transcriptional regulation of steroidogenic enzymes within the gonad and adrenal as well as for the production of GnRH (11, 12) and gonadotropins (13). The relationship between the activities of the two proteins is complex, as not only does SF-1 transcriptionally modulate DAX-1 (14, 15), but DAX-1 inhibits the molecular function of SF-1 (16, 17, 18). This coregulatory interaction requires the C-terminal region of the DAX-1 molecule (17, 19), the most frequent site of mutations in patients with AHC. Analysis of DAX-1 from AHC-affected patients has confirmed that the protein contains a number of critical functional domains (19, 20). Truncation of the C-terminal region by nonsense or frameshift mutations accounts for the majority of mutations detected in subjects with AHC (2, 8, 20, 21, 22, 23, 24). The degree of truncation correlates with the complexity and polarization of clinical symptoms (25, 26). Similarly, missense mutations can result in late-onset (5, 27) or early-onset (28, 29) adrenal insufficiency. So although mapping missense mutations within the DAX1 gene suggests that there are functional domains within the C terminus of the DAX-1 molecule (28), how these affect DAX-1 function is probably dependent on molecular interactions with other transcription factors (30, 31, 32).
Relying on the degree of protein truncation to predict the severity of phenotype may result in confusion if not linked to assays of mutant gene function (2, 8, 20, 21, 22, 23, 24), and analysis of missense mutations (5, 28) is fraught with the same difficulty. Analysis of the clinical phenotype of the individual and affected kindred seems the only critical test. In the present study we describe two adults with AHC and hypogonadotropic hypogonadism in whom we have identified DAX-1 mutations. One resulted in a premature stop codon at amino acid 399 (Y399X), predicted to result in synthesis of a protein lacking 71 amino acids from the C terminus. The second had a novel missense mutation that converted a leucine residue conserved in the mouse and human sequences (20) to a proline (L297P). Functional effects of the mutations were investigated using transient transfection analyses of DAX-1 expression constructs. Immunohistochemical analysis of the testes from the deceased sibling of one patient showed normal development of Sertoli cells and fetal-type germ cells. These data enlarge on the clinical features and molecular functionality associated with DAX-1 mutations.
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Materials and Methods |
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This project received approval from the Lothian pediatrics and reproductive medicine ethics committee, and subjects gave informed consent in writing. Blood samples for DNA extraction and analysis were obtained from the two probands, JM and RW, and in both cases from their mothers and only sisters. The positive control sample was obtained from a healthy fertile male. Tissue samples of testis from JM’s elder male sibling were obtained from the archive of the Pathology Department, Royal Hospital for Sick Children, for analysis with the knowledge and consent of his mother.
DNA extraction, sequencing, PCR, and mutation analysis
DNA was extracted from 300 µl whole blood using the Genomic DNA extraction kit (Amersham Pharmacia Biotech, Little Chalfont, UK). All PCR primers, including those based on published sequences (23), are listed in Table 1
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A 143-bp region of the DAX-1 gene in subject JM and his mother and sister was amplified as described above, covering the Y399X mutation in exon 2 (Table 1
), purified using High Pure PCR clean-up kit (Roche, Lewes, UK), and subjected to analysis with RsaI (Promega Corp. UK Ltd., Southampton, UK) or Tsp509I (New England Biolabs, Inc., Hitchin, UK) restriction enzymes. Cleaved PCR products were fractionated on 2% agarose gels stained with 10 µg/ml ethidium bromide and visualized.
Cloning of DAX1 gene and transfection analysis
Specific primers (Table 1) amplified the DAX-1 gene as a 4913-bp PCR product using the same conditions as above, but with a graded extension of 10 cycles at 72 C for 30 sec, which increased by 20 sec/cycle in cycles 10–30. The PCR products from the probands and the control subject were cloned into pCR3.1 (Invitrogen, Paisley, UK), and at least 3 clones of each were sequenced in the forward and reverse orientations.
For in vitro studies of DAX-1 function, a full-length mouse SF-1 cDNA clone (gift from Dr. K. Parker, Dallas, TX) was ligated into pcDNA3 (Invitrogen, Paisley, UK). In addition, sense 5'-cGCCTCTCCCTGACCTTGTCTGCCTCTCGCg-3' and antisense ctagCGCGAGAGGCAGACAAGGTCAGGGAGAGGCggtac-3' oligonucleotides containing three copies of the SF-1 DNA-binding site (uppercase) and the core-binding site (underlined), from the LH ß-subunit gene promoter (33) were synthesized (Sigma-Genosys, Pampisford, UK) with overhanging KpnI and NheI sites (lowercase), annealed, and ligated upstream of a minimal TK promoter in the p-TAL vector (BD Biosciences-CLONTECH Laboratories, Inc., Oxford, UK) to form SF-1/ptk-luciferase (LUC).
HeLa cells (ECACC, CAMR, Porton Down, UK) were passaged in DMEM, 10% fetal calf serum, and 1% penicillin/streptomycin at 37 C in a humidified 5% CO2 atmosphere. A Fugene 6 (Roche) transfection mix of 1.5 µg SF-1/ptk-LUC or ptk-LUC empty vector, with 250 ng SF-1/pcDNA3 and 100 ng ß-galactosidase/well was supplemented with either 125 ng pBluescript II (Stratagene Europe, Amsterdam, The Netherlands) or increasing amounts of DAX-1 expression construct and transfected into the HeLa cells. LUC and ß-galactosidase activities were determined 48 h later using a Dual-Light assay kit (PerkinElmer, Cambridge, UK) in an LB96V luminometer (Bertold Technologies, Bad Wildbad, Germany). Results calculated from three separate experiments, each performed in triplicate, are expressed as relative light units x 103 and presented as the mean ± SEM.
Immunohistochemistry
A tissue block containing a testicular tissue fragment of an elder sibling of subject JM who had died at age 23 d was obtained from the archives at the Edinburgh Hospital for Sick Children. Sections (5 µm) were stained with hematoxylin or used to perform immunohistochemistry with antibodies directed against anti-Mullerian hormone (AMH; gift from R. Rey and N. Josso), aromatase (prepared in-house) (34), human DAX-1 (raised against an N-terminal peptide; Santa Cruz Biotechnology, Inc., Santa Cruz, CA), or SF-1 (gift from K. Morohashi, Okazaki, Japan). All antibodies were raised in rabbits, except for that directed against aromatase, which was a mouse monoclonal. Immunohistochemistry was performed according to a standard protocol previously described in detail (34, 35). Sections to be incubated with antibodies directed against AMH, SF-1, and DAX-1 were all subjected to heat-induced antigen retrieval in glycine buffer, pH 3.5 (DAX-1) or pH 8 (SF-1 and AMH), as described previously (35). Sections were incubated with 3% hydrogen peroxide in methanol for 30 min to block endogenous peroxidase. Primary antibodies were used at the following dilutions: anti-DAX-1, 1:60; anti-AMH, 1:200; anti-SF-1, 1:150; and antiaromatase, 1:60. Sections were incubated with the appropriate biotinylated secondary antibodies, either swine antirabbit or rabbit antimouse (both from DAKO Corp., Cambridge, UK), diluted 1:500. Incubations lasted for 1 h and were followed by two washes in Tris-buffered saline (5 min each). Thereafter, sections were incubated in avidin-biotin-peroxidase/horseradish peroxidase complex (DAKO Corp.) for 1 h and washed in Tris-buffered saline (twice, 5 min each time), and bound antibodies were visualized by incubation with 3,3'-diaminobenzidine tetrahydrochloride (liquid DAB, catalog no. K3468, DAKO Corp.). Sections were counterstained with hematoxylin. Images were captured using a Provis microscope (Olympus Corp., London, UK) equipped with a Kodak DCS330 camera (Eastman Kodak Co., Rochester, NY), stored on a Macintosh PowerPC computer (Cupertino, CA) and assembled using Photoshop 6 (Adobe, Mountain View, CA).
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Results |
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JM first presented age 10 d with vomiting and hyperkalemia. Adrenal insufficiency was diagnosed and treated with cortisone. Adrenal function was subsequently assessed as adequate by a Thorn test at age 2 yr (50% fall in eosinophils after 20 U ACTH), and in response to ACTH at age 5 yr. Height, weight, and bone age were normal at that time. However, at age 7 yr he suffered an Addisonian crisis and was subsequently maintained on cortisone and salt; the salt was replaced by fludrocortisone at age 8 yr.
He was reinvestigated at age 14 yr. In response to 250 µg Synacthen, plasma cortisol rose briefly from 25 to 1208 nmol/liter at 30 min, but fell to 541 nmol/liter at 90 min. However, urinary 17-hydroxycorticosteroids were reported as undetectable, and the baseline ACTH concentration was markedly elevated at 366 mU/liter (1462 ng/liter). He showed evidence of spontaneous onset of puberty from age 14 yr, with serum testosterone rising to 9.7 nmol/liter at age 15 yr, but he subsequently developed hypogonadotropic hypogonadism, and testosterone replacement therapy was instigated (Table 2).
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Case report 2 (RW)
The subject was evaluated at age 34 yr. The subject had received cortisone replacement since a salt-loosing crisis at age 5 wk, and testosterone had been introduced at age 24 yr after failure of spontaneous puberty. On withdrawing testosterone replacement for 8 wk, he was confirmed to have hypogonadotropic hypogonadism with LH below 1.0, FSH of 1.5 IU/liter, and testosterone of 2.9 nmol/liter. Administration of GnRH (50 µg, iv) resulted in no change in either LH or FSH concentrations. However, administration of hCG (3000 IU twice weekly) resulted in rapid normalization of testosterone secretion (13 nmol/liter at 3 wk). After 9 months of treatment with continued hCG administration in combination with FSH (150 IU three times weekly), he remained azoospermic. The serum inhibin B concentration before gonadotropin administration was 112 pg/ml and rose slightly to 144 pg/ml after 7 months of gonadotropin treatment. Testicular volumes remained 3 ml bilaterally. Testosterone replacement therapy was reinitiated thereafter.
Kindred analysis and identification of nucleotide mutations
Subject JM.
Kindred JM are Scottish (Fig. 1A). JM’s older sibling had died at age 23 d (Fig. 1A; III-AHC); he had presented at 16 d of age with vomiting. Postmortem examination revealed very small adrenal glands (combined weight, 0.68 g) with abnormal architecture with large vacuolated irregularly arranged cells. A diagnosis of AHC was made: other organs, including pituitary gland and testes, appeared of normal size. The proband’s mother (Fig. 1A; II-1) was interviewed to determine whether other family members had been diagnosed with AHC, and blood samples were obtained from close family members. DNA sequencing of amplified PCR fragments (Fig. 1B) identified a C
A transversion in the second exon of the DAX-1 gene (arrow) and established that the proband was hemizygous; his mother was heterozygous, but his sister did not carry the mutation. This transversion altered the restriction enzyme recognition sequence for RsaI and introduced one recognized by Tsp509I. Changes in the DNA sequence of the JM kindred were confirmed by gel analysis after digestion of a 143-bp fragment (Fig. 1B). RsaI cleaved control 143-bp PCR products into 59- and 84-bp fragments, whereas Tsp509I did not cleave control DNA, but did cleave DNA carrying the point mutation into 57 and 86 bp. This point mutation alters a tyrosine into a stop codon (Y399X) and so truncates the DAX-1 protein by 71 amino acids (Table 3).
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; V-AHC), who has also been diagnosed with AHC, although no kindred analysis was reported (29). Kindred JM has three family members with AHC, establishing that this mutation has been inherited from previous generations and has not occurred de novo. The high neonatal morbidity in JM’s siblings (III-c and -d) was due not to AHC, but to other complications (prematurity and spina bifida). However, it is noteworthy that in generation III there were two stillborn male siblings (III-b) and a number of family members do not have children (III-a and IV-a), although further details are not available.
Subject RW.
Kindred RW is English in origin (Fig. 1C). Again, an elder sibling had previously been diagnosed with AHC at postmortem examination, having died in the neonatal period (Fig. 1C; II-AHC). DNA sequencing of the DAX-1 gene in RW’s family identified a single occurrence of a TC transversion in the proband, and both his mother and sister were heterozygous for this mutation (Fig. 1C; I-1 and II-2). This transversion changes the encoded amino acid sequence from leucine to proline, causing a missense mutation in codon 297 in the first exon of the DAX-1 gene (Table 3). This missense occurs within a recognizable amino acid LLXLXL repeat motif of the protein, changing it to LLXPXL (Table 3).
Analysis of the complete DAX-1 cDNA for both patients revealed that there were no other alterations in the nucleotide coding sequence that differed from published data or from the control.
Gene expression studies
The coregulatory interaction between DAX-1 and SF-1 was used to assay repressor activity of DAX-1 constructs (17, 19), as DAX-1 represses SF-1 mediated trans-activation of promoter constructs. SF-1 trans-activation of the LH ß-subunit gene promoter is required for fertility (13), so a reporter construct containing three copies of the SF-1 DNA-binding site from the LHß gene promoter was constructed (33, 36, 37, 38). The effects of the identified nonsense and missense mutations on function of the DAX-1 protein were tested in vitro and compared with controls (Fig. 2). The DAX-1 control efficiently repressed SF-1-mediated trans-activation at low concentrations (16 ng); cotransfection of high amounts (63,125 ng) of control DAX-1 expression vectors further reduced SF-1/ptk-LUC gene expression levels well below basal levels, but this may be due to transcriptional interference and has been noted by others when high concentrations of DAX-1 are transfected in vitro (39). In contrast, neither Y399X nor L297P DAX-1 mutant efficiently repressed SF-1 trans-activation at low concentrations (16 ng). It is notable that the missense L297P mutation affected DAX-1 protein function as profoundly as the nonsense Y399X mutation (Fig. 2).
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Examination of tissue sections revealed the presence of well defined seminiferous testis cords containing numerous Sertoli cells and germ cells surrounded by an interstitial region (Fig. 3A). The presence of functionally competent Sertoli cells was confirmed by immunopositive cytoplasmic staining for AMH (Fig. 3B). At high power magnification testis cords were clearly surrounded by a layer of peritubular cells (small arrows) and contained numerous large round cells identified as germ cells (gonocytes or spermatogonia; large arrows in B). The interstitium contained cells tentatively identified as Leydig cells. We have previously demonstrated expression of DAX-1 protein in human fetal testes (40) and used the same antibody that is directed against the N terminus of human DAX-1 to demonstrate that immunopositive Sertoli cells (arrows in Fig. 3C) could be identified, although background staining was present. Sertoli cell nuclei were also immunopositive for SF-1 (Fig. 3D). No immunopositive staining for aromatase was detected (not shown).
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Discussion |
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There are a number of apparent anomalies when correlating DAX-1 mutations with phenotype. Most patients with DAX-1 mutations present in infancy, but adrenal function can recover over a number of years. This was clearly demonstrated by JM and has been reported in patients up to 13 yr of age (8, 21). The basis for this is unclear, as it does not correlate with the molecular diagnosis (2, 23), and intriguingly the timing of onset of symptoms varies with the same mutation (41). The C-terminal region of DAX-1 (amino acids 253–470) shows significant homology to the ligand-binding domain of members of the nuclear hormone family and is required for functional activity (17). It is notable that in the paper by Ito et al. (17) deletion of the C-terminal part of the protein, analogous to the situation in patient JM, resulted in no reduction in binding to SF-1 protein; these researchers identified an inhibitory domain between amino acids 443 and 470 at the extreme C terminus of the protein. Evidence for discrete repressor domains within the C-terminal region can also be mapped by clusters of DAX-1 mutations (20, 28), which may in part explain anomalies between the DAX-1 gene mutation and the clinical phenotype in AHC. That the loss of 71 amino acids in the Y399X mutation was as damaging to DAX-1 repressor activity as the L297P point mutation provides further illustration that the degree of protein truncation may not predict the severity of phenotype if not linked to an assay of mutant gene function.
The Y399X mutation identified in JM has been previously reported in subject LP (29), and it has now emerged that they are of the same kindred. In that report only limited clinical information on LP is given. As LP is still a child, the information presented here on subject JM adds significantly to the phenotype of this mutation. A similar mutation has been reported previously as case 1 by Nakae et al. (21). In their subject a mutation resulted in a change at amino acid 395 resulting in a truncated protein (Q395X). This subject presented rather later in life than JM, at age 6 yr, and showed no signs of spontaneous puberty. He did, however, show a normal response to hCG administration. JM also showed a normal response to hCG administration when first tested in early spontaneous puberty, but subsequently became unresponsive. The case presented by Nakae et al. (21) was assessed at age 21 yr; thus, it is possible that later assessment may have revealed a change in responsiveness to hCG.
The L297P mutation identified in RW has not been previously reported, although an L295P has recently been identified (42), but with no information on the phenotype of the patient. Notably, another missense mutation (A300V), located three amino acids nearer the C terminus, has been reported to have a variable phenotype: one family member was diagnosed with adrenal failure and delayed puberty at age 15 yr, while another developed adrenal failure as a neonate (7, 43). The latter also showed hypothalamo-pituitary-gonadal activity for the first 3 yr of life. These comparisons illustrate the complexity of relating phenotype to genotype, especially when the phenotype shows significant alterations over time. Zhang et al. (20) have published a three-dimensional model of the DAX-1 protein. Interestingly, the position of the mutated amino acid (297) in RW maps within a highly conserved site that has been proposed to be of major functional significance for transcriptional silencing (19). The amino acid motif LLXLXL surrounding the mutation site is known to be important for coregulator recruitment (44) in ligand-activated nuclear receptors, and the insertion of a proline within this region occurs within the same LLXLXL motif as a newly reported L295P mutation (42). DAX-1 represses transcription via recruitment of corepressors (30, 31) that are also required for coregulatory interaction with SF-1 (30), indicating that disruption of this motif implicates it as an integral part of the repressor domains contained within the C terminal of the DAX-1 molecule.
Hypogonadotropic hypogonadism has been invariably found in association with AHC in subjects with DAX-1 mutations and may have both hypothalamic and pituitary components (45). Interstitial cells are present in the testis from the sibling of JM at the time of his death at age 23 d. Both subjects in this study had low or undetectable basal gonadotropin secretion that did not respond to GnRH administration, either as single dose or during prolonged pulsatile administration. However, testosterone was secreted in response to hCG by the patient carrying the L297P mutation. JM had shown some evidence of initiation of puberty when assessed at age 15 yr, suggesting that his testes contained functional Leydig cells at that time, but they became unresponsive thereafter. In support of this, clinical examination of the testes noted an increase in volume that was not sustained, and corresponding plasma testosterone concentrations fell. Genital size is generally normal in childhood, and the hypothalamic-pituitary-testicular axis can be active (7, 8, 23). Spontaneous puberty followed by progressive gonadotropin deficiency has been described in association with DAX-1 mutations (46). Limited data are available regarding response to hCG administration in adulthood, although the response during adolescence may be normal (24, 27, 47, 48). These changes demonstrate a progressive evolution of the course of the condition, with the gonadal effects of DAX-1 deficiency manifesting at different stages through the neonatal period, childhood and adolescence, and adulthood. Interestingly, JM also showed evidence of a degree of adrenal responsiveness at age 15 yr, although the response was short-lived.
It has been suggested that in addition to playing a role in modulation of the hypothalamic-pituitary-testicular axis, DAX-1 may have direct effects within the testis. DAX-1 is expressed in Sertoli cells and interstitial cells in rats (40, 49). The testes from the older brother of JM had a grossly normal morphology at 23 d of age and contained numerous germ cells as well as Sertoli cells capable of synthesizing AMH, SF-1, and the truncated DAX-1 protein. A role for DAX-1 in spermatogenesis is supported by the report of an individual with a very mild AHC phenotype with oligospermia who was unresponsive to gonadotropin administration (5). The inability to induce spermatogenesis despite gonadotropin therapy in this and previous reports (26, 27) suggests that although germ cells may be present in the testes of adults with DAX-1 mutations, there appears to be a defect in spermatogenesis additional to coexisting hypogonadotropism that may be due to direct effects on Sertoli cell function. This interpretation is further supported by the significant serum concentration of inhibin B in RW, consistent with the presence of germ cells within the testis (50, 51), although in the mild case described by Tabarin et al. (5), inhibin B was at the limit of detection. Low concentrations were found in subject JM. These data therefore increase the spectrum of the testicular phenotype in DAX-1 mutations.
The description of testicular morphology in a sibling with AHC who died has also allowed us to make further comparisons with the effects of DAX-1 gene manipulation in the mouse. Immunohistochemical analysis showed that DAX-1 protein was expressed in the testis, using an antibody directed against the presumed conserved N terminus of the molecule. This result demonstrates for the first time in vivo expression of truncated DAX-1 in human testis. Interestingly, in a patient with a closely related mutation [case 1, (21)], mRNA expression of the mutated DAX-1 was detected in the testis. DAX-1 may function differently in mice, as gene-disrupted DAX-1 mice show abnormal differentiation of Leydig and Sertoli cells and progressive degeneration of the seminiferous epithelium (52, 53), and DAX-1 expression in intact Sertoli cells can rescue infertility (53). These abnormalities were not apparent in human neonatal tissue. We also found no evidence of overexpression of aromatase, which has been described in the Leydig cells of DAX-1-knockout mice (39), although this may have been because levels of the protein were too low to be detected immunohistochemically. It is likely that these differences reflect in part the developmental stages examined in humans and mice and may reflect the postinfancy onset of the testicular lesion in the human. However, it is unclear whether the changes observed in the mouse are of relevance to the human phenotype of this condition. We are not aware of any reports of testicular histology in adult humans with DAX-1 mutations.
In conclusion, the two individuals reported here add to the clinical and genetic data on AHC and hypogonadotropic hypogonadism in association with DAX-1 mutations. These data confirm the potential for recovery of adrenal function for several years during childhood and the loss of gonadal function at puberty. Normal fetal and neonatal development of the testis is suggested by examination of a sibling with AHC who died.
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Acknowledgments |
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Footnotes |
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Received October 7, 2002.
Accepted December 5, 2002.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Endocrinology | Endocrine Reviews | J. Clin. End. & Metab. |
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, Hemizygous males; 
, heterozygous carrier females. Generations are indicated in Roman numerals, and additional information is identified by lowercase letters or numbers. A, Kindred JM has five generations. Genotyping was performed on numbered individuals. Lowercase letters correspond to: a, no children; b, stillborn; c, spina bifida; d, neonatal death. LP denotes an individual reported in Ref. 
