Adrenal Hypoplasia Clinical Presentation

  • Author: Thomas A Wilson, MD; Chief Editor: Stephen Kemp, MD, PhD   more...
 
Updated: Mar 1, 2012
 

History

  • Congenital adrenal hypoplasia most commonly presents in the neonatal period but may not become apparent until later in childhood.
  • Patients often present in crisis with dehydration, hyponatremia, hyperkalemia, hypotension, or hypoglycemia.
  • Patients with adrenal hyperplasia secondary to intrauterine growth retardation, metaphyseal dysplasia, adrenal hypoplasia congenita, genital anomalies (IMAGe) association have a history of intrauterine growth retardation. Males have genital abnormalities.
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Physical

  • Patients may demonstrate hyperpigmentation from increased serum concentrations of adrenocorticotropic hormone (ACTH).
  • Signs of dehydration are often present.
  • Hypotension and symptoms of neuroglycopenia may be present.
  • Testes are undescended in many patients; micropenis may be seen in subjects with hypogonadotropic hypogonadism. Hypospadias or cryptorchidism may be seen in patients with IMAGe association.
  • Hearing loss may be an associated finding.[11]
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Causes

  • X-linked congenital adrenal hypoplasia is due to mutation in, or deletion of, the DAX1 (AHCH) gene. The AHCH gene is located on chromosome bands Xp21.3-Xp21.2 and is thought to code for a nuclear receptor; however, the ligand for this particular nuclear receptor is not known, and hence, it is called an orphan nuclear receptor.
  • The DAX1 gene is also expressed in an alternatively spliced transcript, DAX1a. DAX1 and DAX1a appear to heterodimerize and also dimerize with SF1.[10] DAX1 appears to suppress expression of the SF1- regulated steroidogenic acute regulatory (StAR) protein promoter. How loss of this function results in loss of hypothalamic and adrenal cortical development remains unclear. DAX1 also appears to function as an antitestis gene by acting antagonistically to the sex-determining region (SRY).[12] In mice, DAX1 or AHCH is essential for the maintenance of spermatogenesis. Lack of the gene product causes progressive degeneration of the testicular germinal epithelium independent of abnormalities in gonadotropin and testosterone production. These changes result in male sterility. Excess expression of DAX1 in the male mouse results in reversal of phenotypic sex.
  • DAX1 gene mutations result in significant genotypic-phenotypic variability.[13, 14, 15, 10]
    • In one family, a DAX1 mutation resulted in congenital adrenal hypoplasia and hypogonadotropic hypogonadism in two brothers. A normal phenotype was found in the affected maternal grandfather, and hypogonadotropic hypogonadism with normal adrenal function was found in a maternal aunt who was homozygous for the mutation.[16]
    • The "minipuberty" infancy may be preserved.[17] Ovaries are intact in affected women.
    • Observations in the SF1 knockout mouse and in humans indicate that mutations in SF1 result in congenital adrenal hypoplasia and hypogonadotropic hypogonadism as well. In contrast to DAX1 mutations, however, the phenotype in SF1 defects extends to XY sex reversal (ie, XY karyotype and female external genital appearance), persistence of müllerian structures in XY individuals, and failure of gonadal development (streak gonads).
  • DAX1 and SF1 messenger ribonucleic acid (mRNA) are expressed in the developing urogenital ridge, gonads, adrenal gland, pituitary gland, and hypothalamus, suggesting a dose-dependent role for both of these genes interacting as transcription factors important in a cascade of developmental gene expression.[18]
  • Because the gene involved in the autosomal recessive form of the disease is not known, the cause is even less understood.
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Contributor Information and Disclosures
Author

Thomas A Wilson, MD  Professor of Clinical Pediatrics, Chief and Program Director, Division of Pediatric Endocrinology, Department of Pediatrics, The School of Medicine at Stony Brook University Medical Center

Thomas A Wilson, MD is a member of the following medical societies: Endocrine Society, Pediatric Endocrine Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Phyllis W Speiser, MD  Chief, Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Professor of Pediatrics, Hofstra-North Shore LIJ School of Medicine at Hofstra University

Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry B Bercu, MD  Professor, Departments of Pediatrics, Molecular Pharmacology and Physiology, University of South Florida College of Medicine, All Children's Hospital

Barry B Bercu, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Federation for Clinical Research, American Medical Association, American Pediatric Society, Association of Clinical Scientists, Endocrine Society, Florida Medical Association, Pediatric Endocrine Society, Pituitary Society, Society for Pediatric Research, Society for the Study of Reproduction, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Merrily P M Poth, MD  Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences

Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD  Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

References

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  10. McCabe ER. DAX1: Increasing complexity in the roles of this novel nuclear receptor. Mol Cell Endocrinol. Feb 2007;265-266:179-82. [Medline].

  11. Lin L, Gu WX, Ozisik G, et al. Analysis of DAX1 (NR0B1) and steroidogenic factor-1 (SF1/Ad4BP, NR5A1) in children and adults with primary adrenal failure: ten years' experience. J Clin Endocrinol Metab. May 9 2006;[Medline]. [Full Text].

  12. Manna PR, Dyson MT, Jo Y, Stocco DM. Role of dosage-sensitive sex reversal, adrenal hypoplasia congenita, critical region on the X chromosome, gene 1 in protein kinase A- and protein kinase C-mediated regulation of the steroidogenic acute regulatory protein expression in mouse Leydig tumor cells: mechanism of action. Endocrinology. Jan 2009;150(1):187-99. [Medline].

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  20. Heckmann M, Hartmann MF, Kampschulte B, et al. Cortisol production rates in preterm infants in relation to growth and illness: a noninvasive prospective study using gas chromatography-mass spectrometry. J Clin Endocrinol Metab. Oct 2005;90(10):5737-42. [Medline].

  21. Kazlauskaite R, Evans AT, Villabona CV, et al. Corticotropin tests for hypothalamic-pituitary- adrenal insufficiency: a metaanalysis. J Clin Endocrinol Metab. Nov 2008;93(11):4245-53. [Medline].

  22. Schurmeyer TH, Avgerinos PC, Gold PW, et al. Human corticotropin-releasing factor in man: pharmacokinetic properties and dose-response of plasma adrenocorticotropin and cortisol secretion. J Clin Endocrinol Metab. Dec 1984;59(6):1103-8. [Medline].

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