Extern Conference 17th May 2007

History Chief complaint A 6 week-old girl was referred to our hospital with history of severe vomiting for 3 days

History History of present illness 3 days before admission, she had severe vomiting and lethargy without fever, diarrhea or dysuria. She was admitted to a local hospital. Her investigation: serum electrolyte study revealed Na+ 122 mmol/l, K+ 7.1 mmol/l, Cl- 84 mmol/l, HCO3- 15 mmol/l blood sugar was 126 mg/dl.

History History of present illness 24 hours after admission, she developed generalized tonic clonic seizure, and cyanosis but she had no bladder or bowel incontinence during convulsion. She received initial treatment and was referred to Siriraj hospital.

History Birth history G2P1A0 No maternal drug or hormonal usage Antepartum G2P1A0 No maternal drug or hormonal usage No complication of pregnancy Intrapartum Cesarean section due to previous cesarean section Term AGA infant, birth weight 3,200 g (P50) Apgar score 10, 10 at 1, 5 minute Ambiguous genitalia

History Family history : The second child of family Her sister is healthy. No consanguinity No history of ambiguous genitalia, precoccious puberty or neonatal death in her family Drug History: No history of drug or food allergy

History Nutrition: Breastmilk and formula every 2 hours

Physical examination Vital signs: General appearance: Skin: T 37.5° C, pulse 131 bpm regular, BP 99/49 mmHg (P75-P90), RR 48 /min Weight 3,600 g (P3-P10), Length 53 cm (P10-P25), Head circumference 37 cm (P50) General appearance: Lethargy, not pale, no jaundice, no sign of dehydration Skin: Mild hyperpigmentation at nipple and genitalia

Physical examination Head, eye, ear, nose and throat: AF 2 x 2 cm. PF fingertip, no dysmorphic features Respiratory system: Normal breath sound, no adventitious sound Cardiovascular system: Normal S1 and S2, no murmur, capillary refill less than 2 seconds Abdomen: Soft, not tender, liver and spleen not palpable, no palpable mass

Physical examination Extremities: Nervous system: Genitalia: No deformity Nervous system: Grossly intact Genitalia: Phallus: length 3.3 cm, width 1.2 cm Fused labioscrotal fold with few rugae and hyperpigmentation, no palpable gonad Single urethral opening at perineoscrotal region

Problem list: 2 month-old girl with Ambiguous genitalia without palpable gonad Severe vomiting and lethargy for 3 days Failure to thrive Dehydration Mild hyperpigmentation at nipples and genitalia Hyponatremia, hyperkalemia and wide anion gap metabolic acidosis Mineralocorticoid deficiency

Approach to ambiguous genitalia Gonad palpable Gonad not palpable* Male pseudohermaphroditism True hermaphroditism Female pseudohermaphroditism

Female pseudohermaphroditism Definition The situation where chromosomal and gonadal gender are female but the external genitalia resembling male. Androgen excess is the key

Differential diagnosis Congenital adrenal hyperplasia (CAH) Maternal androgen excess Aromatase deficiency Androgenic target hypersensitivity Multiple congenital malformations Unknown etiology

Congenital Adrenal Hyperplasia The most common cause of ambiguity in the newborn Autosomal recessive pattern of inheritance (Mutation in chromosome 6p21.3) An enzymatic defect in adrenal steroid biosynthesis 90% of CAH caused by 21-Hydroxylase deficiency A type of primary adrenal insufficiency

Renin angiotensin aldosterone system and K+ The adrenal gland Renin angiotensin aldosterone system and K+ Adrenal cortex Zona glomerulosa (15%) aldosterone Zona fasciculata (75%) cortisol Zona reticularis (10%) androgen Adrenal medulla CRH and ACTH CRH and ACTH CRH and ACTH

Steroid biosynthesis

Congenital adrenal hyperplasia It was classified into 3 forms Salt wasting 21-hydroxylase deficiency (classic form) about 2/3 of all patients Virilizing 21-hydroxylase deficiency Non-classic 21-hydroxylase deficiency

Salt wasting 21-hydroxylase deficiency Glucocorticoids and mineralocorticoids deficiency Salt wasting crisis since infancy (7-14 days old) Failure to thrive, vomiting, hypotension Cortisol deficiency stimulate the production of ACTH which cause hyperpigmentation Androgen excess Female infant: Ambiguous genitalia since birth, which range from fused labioscrotal folds to perineal hypospadia Male infant: Normal genitalia, usually presented with signs and symptoms of adrenal insufficiency

Salt wasting 21-hydroxylase deficiency Mineralocorticoid deficiency Salt craving Malaise Weight loss Hypotension or shock Hyponatremia Hyperkalemia Metabolic acidosis  Plasma renin activity Corticosteroid deficiency Hypoglycemia Hyponatremia Hypotension or shock Malaise Poor appetite Weight loss Nausea, vomiting Abdominal pain

Salt wasting 21-hydroxylase deficiency Severe clitoral hypertrophy from masculinization of the external genitalia of a 46,XX patient caused by CAH 22

Virilizing 21-hydroxylase deficiency Glucocorticoids deficiency but not for mineralocorticoids No salt wasting crisis Androgen excess Female Pseudohermaphroditism Male Precocious puberty

Nonclassic 21-hydroxylase deficiency Mild degree of hyperandrogenism Female PCOD, acne, hirsutism, infertility, irregular menstruation Male Precocious puberty, advanced bone age, accerelated growth during childhood

Diagnosis of CAH Hormonal study 17-hydroxyprogesterone level is diagnostic Progesterone level Testosterone level Cortisol level (take critical sample before treatment) 250 mcg ACTH stimulation test in borderline case Imaging study Pelvic ultrasonography for gonads and female internal sex organs Chromosomal study To confirm gender DNA Analysis

Diagnosis of CAH

Diagnosis of CAH Hormonal study Imaging study Chromosomal study Result pending Hormonal study 17-hydroxyprogesterone level is diagnostic Progesterone level Testosterone level Cortisol level (take critical sample before treatment) 250 mcg ACTH stimulation test in borderline case Imaging study Pelvic ultrasonography for gonads and female internal sex organs Chromosomal study To confirm gender in the non-palpable gonad cases DNA Analysis 61 ng/dl (normal 7-59 ng/dl)* 20 ng/dl (normal < 10 ng/dl)* Pre-pubertal uterus with bilateral ovaries and no visualization of the testes 46, XX Result pending

Treatment of adrenal crisis Glucocorticoids replacement Hydrocortisone 100 mg/m2/day Fluid replacement NSS 10-20 cc/kg in 30-60 minutes, then 5%D/NSS to 5%D/N/2 20 cc/kg Hypoglycemia 2-3 cc/kg of 25% dextrose iv bolus Hydrocortisone 309 mg/m2/day 5% D/N/5 (MT+7% def)

Treatment of adrenal crisis Hyponatremia Deficit therapy: ΔNa x 0.6 x BW Replacement half of the deficit in 8-12 hours MT: 2-3 mEq/kg/day Hyperkalemia EKG monitoring if K+ > 6 mmol/l: kayexalate po. or by enema if K+ > 7 mmol/l: NaHCO3 1-2 mmol/kg iv if EKG abnormality: 10% Calcium gluconate 0.5-1 cc/kg iv in 10 minutes

Maintenance treatment in CAH Glucocorticoids replacement To suppress adrenal androgen Hydrocortisone (Cortef®) (12-18 mg/m2/day1) Mineralocorticoids replacement To return normal electrolytes and plasma renin activity Fludrocortisone (Florinef®) (0.05-0.3 mg/day) NaCl supplement in infant 1-3 g/day added to formula or foods Beware of hypertension 1 Merke D P, Bornstein S R. Lancet 2005; 365: 2125-36

Maintenance treatment in CAH Stress dosing Increase hydrocortisone dosage to 3-5 folds of normal daily dosage Same fludrocortisone dosage Undesired effect of treatment Excessive cortisol replacement in infancy cause short stature in adulthood Measure weight, length, adrenal steroid level, plasma renin activity and serum electrolytes

irritable & poor feeding Date 25/4/50 26/4/50 29/4/50 3/5/50 4/5/50 6/5/50 8/5/50 11/5/50 14/5/50 BW (g) 3,600 3,640 3,680 4,000 4,150 4,300 4,470 4,620 4,750 Na /K (mmol/l) Cl /HCO3- (mmol/l) 135/4.2 100/15 134/4.2 101/19 133/5.7 96/18 135/6.2 100/21 137/4.2 101/21 138/5.0 105/18 139/4.7 103/23 138/5.9 105/13 135/4.5 101/22 BUN/Cr (mg/dl) 6/0.3 Treatment Cortef (mg/m2/d) Florinef (g/d) Na+ replacement (g/d) 100 0.1 1 72 2 55 0.2 0.15 43 30 48 1.5 EKG normal TFT Urine Na /K (mmol/l) Cl (mmol/l) 33/1.9 25 Clinical irritable & poor feeding URI afebrile active D/C This slide shows clinical coarse of the patient when she was admitted in Siriraj hospital. During weaning off hydrocortisone from stress dose to maintenance dose, her clinical, body weight, blood pressure and serum electrolytes were monitored regularly. Because the mineralocorticoids effects of hydrocortisone we may have to increase the dosage of fludrocortisone when tapering off hydrocortisone. Such as these days when serum electrolytes showed the picture of mineralocorticoid deficiency, so we adjusted the fludrocortisone dosage and the electrolyte returned to normal. In this day (11/5/50), she had URI symptoms, that was a stress, and loosed her weight for 70 grams in 24 hours, so we increased the hydrocortisone dosage from 30 to 48 mg/sqm/day, maintained this for a week and weaned to 30 mg/sqm/day, which is the maximal dosage that does not effect the growth. Plan: wean Cortef® to 30 mg/m2/d in three days after discharge

Discharge planning Consult urologist for surgical correction Counseling the parents Medical dosage adjustment in case of stress Signs and symptoms of adrenal crisis Signs and symptoms of cortisol excess Puberty, growth and development Recurrent risk and prenatal diagnosis for the next pregnancy The discharge planning was surgical correction of her genitalia and counseling her parents how to adjust the dosage of hydrocortisone, in case of stress, such as infection. They should know when to bring her child back to the hospital. The side effects of medication on the growth and development. And, finally, if there is a plan for the next child, the recurrent risk is ¼ and prenatal diagnosis would be discussed.

Take home message Newborn with ambiguous genitalia should not go home without follow up CAH is the most common cause of female pseudohermaphroditism Clinical presentation Poor feeding, poor weight gain Inactive, lethargy, vomiting Salt losing begins in the second week of life Follow up clinical and serum electrolytes weekly What the GPs have to know is, when you found the newborn with ambiguous genitalia, never let he or she go back home without follow up. Because newborn with classic CAH, which is the most common cause of female pseudohermaphroditism, begin to show signs and symptoms in the second week of life, so the visits for clinical and serum electrolytes should be scheduled weakly.

Take home message In case of suspected adrenal insufficiency Early diagnosis and treatment is the most important Take the critical sample before start treatment Serum cortisol, glucose, electrolytes And clotted blood 5 ml centrifuge then store serum at 4˚C for hormonal study And if adrenal insufficiency was suspected, don’t forget to take the critical sample before the treatment started. Which are cortisol, glucose, electrolytes and another 5 cc of clotted blood for hormonal study.

Special thanks to ผศ. พญ. จีรันดา สันติประภพ พญ. กานต์สุดา พิเชษสุดา

Thank you for your attention