Prenatal Diagnosis of Congenital Lipoid Adrenal Hyperplasia (CLAH) by Molecular Genetic Testing in Korean Siblings

Abstract

Congenital lipoid adrenal hyperplasia (CLAH) is caused by mutations to the steroidogenic acute regulatory protein (StAR) gene associated with the inability to synthesize all adrenal and gonadal steroids. Inadequate treatment in an infant with this condition may result in sudden death from an adrenal crisis. We report a case in which CLAH developed in Korean siblings; the second child was prenatally diagnosed because the first child was affected and low maternal serum estriol was detected in a prenatal screening test. To our knowledge, this is the first prenatal diagnosis of the Q258X StAR mutation, which is the only consistent genetic cluster identified to date in Japanese and Korean populations.

Full text

Yonsei Med J http://www.eymj.org Volume 52 Number 6 November 2011
1035
Case Report http://dx.doi.org/10.3349/ymj.2011.52.6.1035
pISSN: 0513-5796, eISSN: 1976-2437 Yonsei Med J 52(6):1035-1038, 2011
Prenatal Diagnosis of Congenital Lipoid Adrenal Hyperplasia
(CLAH) by Molecular Genetic Testing in Korean Siblings
Hyun Sun Ko,1 Seungok Lee,2 Hyojin Chae,2 Sae Kyung Choi,1 Myungshin Kim,2
In Yang Park,1 Byung Kyu Suh,3 and Jong Chul Shin1
Departments of 1Obstetrics and Gynecology, 2Laboratory Medicine, and 3Pediatrics,
College of Medicine, The Catholic University of Korea, Seoul, Korea.
Received: April 21, 2011
Revised: May 26, 2011
Accepted: June 1, 2011
Corresponding author: Dr. Jong Chul Shin,
Department of Obstetrics and Gynecology,
College of Medicine,
The Catholic University of Korea,
505 Banpo-dong, Seocho-gu,
Seoul 137-450, Korea.
Tel: 82-2-2258-3021, Fax: 82-2-595-1549
E-mail: jcshin@catholic.ac.kr
∙ The authors have no financial conflicts of
interest.
© Copyright:
Yonsei University College of Medicine 2011
This is an Open Access article distributed under the
terms of the Creative Commons Attribution Non-
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Congenital lipoid adrenal hyperplasia (CLAH) is caused by mutations to the ste-
roidogenic acute regulatory protein (StAR) gene associated with the inability to
synthesize all adrenal and gonadal steroids. Inadequate treatment in an infant with
this condition may result in sudden death from an adrenal crisis. We report a case
in which CLAH developed in Korean siblings; the second child was prenatally di-
agnosed because the rst child was affected and low maternal serum estriol was
detected in a prenatal screening test. To our knowledge, this is the rst prenatal di-
agnosis of the Q258X StAR mutation, which is the only consistent genetic cluster
identied to date in Japanese and Korean populations.
Key Words: Lipoid hyperplasia, congenital, prenatal, sibling
INTRODUCTION
Congenital lipoid adrenal hyperplasia (CLAH) is the most severe form of congeni-
tal adrenal hyperplasia in which the synthesis of all adrenal and gonadal steroid
hormones is impaired, due to mutations to the steroidogenic acute regulatory pro-
tein (StAR) gene.1 Clinical ndings in these patients are salt loss, hypoglycemia,
pigmentation and male sex reversal. Delay in treatment may result in sudden death
from adrenal crisis. While the homozygous c.201-202 delCT StAR mutation has
been prenatally diagnosed in Palestinians, this is the rst prenatal diagnosis of the
Q258X StAR mutation, which is the only consistent genetic cluster identied to
date in Japanese and Korean populations.2-7
CASE REPORT
A 33-year-old G2P1 woman presented to our obstetric unit at 17 weeks’ gestation
for antenatal care of her second pregnancy. Maternal serum screening demonstrat-
ed a very low estriol level of 0.06 multiples of the median (MoM) with low alpha-
fetoprotein (AFP) and human chorionic gonadotropin (hCG) level, 0.6 MoM and
0.52 MoM, respectively, which were interpreted as a high risk of Edward syndrome

Hyun Sun Ko, et al.
Yonsei Med J http://www.eymj.org Volume 52 Number 6 November 2011
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mineralocorticoid, which were tapered to a maintenance dose.
Therefore, prenatal testing was performed in the second
sibling for the relevant disease-causing mutation from fetal
cells by amniocentesis. Exon 7 and its adjacent intronic se-
quences were amplified by PCR, using forward primer
5’-CCTGGCAGCCTGTTTGTGATAG-3’ and reverse
primer 5’-ATGAGCGTGTGTACCAGTGCAG-3’, which
revealed a homozygous c.772C>T substitution resulting in a
glycine to stop codon substitution at amino acid 258 (Fig. 1).
A 2,665 g female baby was delivered vaginally with Apgar
scores of 7 and 9 at 40 weeks’ gestation. At birth, the baby
presented with normal female external genitalia. Screening
for congenital adrenal hyperplasia was normal, 17α-OH
progesterone (17α-OHP) 8.33 ng/mL (normal 1.7-25.0 ng/
mL). There were no clinical signs or symptoms until 3
months after birth. Four months after birth, the second baby
was admitted to our hospital with vomiting and diarrhea af-
ter DTaP vaccination. Her laboratory prole was similar to
that of her sister, but without enlargement of adrenal glands
on ultrasonography (Table 1). Genetic evaluation from the
(1 : 79) and Smith-Lemli-Opitz (SLO) syndrome (1 : 7).8,9
The karyotype by amniocentesis was 46,XX. Level II ultra-
sonography after 21 weeks’ gestation demonstrated no struc-
tural abnormalities including the adrenal glands and genita-
lia. Upon reevaluation of family history, however, the parents
revealed that their 27-month-old first baby had been diag-
nosed with CLAH. The rst baby was delivered vaginally at
36+2 weeks’ gestation with birth weight 2,360 g. Initial
symptoms included projectile vomiting and poor oral intake,
with lethargy and hyperpigmentaion 10 weeks after birth.
The initial laboratory finding demonstrated hyponatremia
(125 mEq/L) and hyperkalemia (6.6 mEq/L). Basal adrenal
hormone levels and an adrenocoticotropic hormone (ACTH)
stimulation test showed a severe deciency of adrenal hor-
mones (Table 1). Abdominal ultrasonography and computed
tomography (CT) demonstrated diffusely enlarged adrenal
glands with markedly low density. Gene analysis revealed a
normal CYP21A2 gene sequence but a homozygous muta-
tion c.772C>T in exon 7 of StAR. She was diagnosed with
CLAH and treated with stress doses of hydrocortisone and
Table 1. Biochemical Characteristics at Initial Diagnosis
Hormones Values of the rst baby Values of the second baby Normal ranges
ACTH 344.77 pg/mL 684.87 pg/mL 10-60 pg/mL
Cortisol 0.53 µg/dL 87.35 µg/dL* 4-19 µg/dL
Renin 26.93 ng/mL 2.35-37 ng/mL
Aldosterone 1.45 ng/dL 0.05 ng/mL 1.5-16 ng/dL
Progesterone 1 ng/dL <9.2 ng/dL
Testosterone 1 ng/dL <3-9 ng/dL
DHEAS 7.50 µg/dL 88-356 µg/dL
17-OHP 0.12 ng/mL 0.14 ng/mL 0.1-0.4 ng/mL
ACTH stimulation test
Cortisol (0 min) 0.53 µg/dL 4-9 µg/dL
(30 min) 0.52 µg/dL
(60 min) 0.52 µg/dL 22-36 µg/dL
17-OHP (0 min) 0.12 ng/mL 0.1-0.4 ng/mL
(30 min) 0.13 ng/mL
(60 min) 0.13 ng/mL 0.92-2.34 ng/mL
ACTH, adrenocoticotropic hormone; DHEAS, dehydroepiandrosterone sulfate; 17-OHP, 17-hydroxyprogesterone caproate.
*This was post hormonal replacement.
Fig. 1. StAR sequencing chromatogram (A: control sample, B: fetus). C to T substitution is expected to produce a glycine to stop codon
substitution.
A T C A T C A A C C A G G T C C T G T A T C A T C A A C T A G G T C C T G T
I II IN NQ XV L
AB

Congenital Lipoid Adrenal Hyperplasia
Yonsei Med J http://www.eymj.org Volume 52 Number 6 November 2011
1037
be reevaluated. First, any family history of disordered ste-
roidogenesis should be sought, followed by a detailed pre-
natal ultrasonography looking for the characteristic features
of SLO syndrome before invasive tests, if required.12
Due to the difculty of establishing a diagnosis of CLAH
from amniotic hormone assays, molecular genetic testing is
often needed.2,14 It is important that infants born to mothers
with low estriol levels of unexplained causes should be eval-
uated postnataly, as soon as possible, to rule out adrenal in-
sufficiency. Also, the affected patients should be closely
monitored in the outpatient clinic, because the majority of
patients present during the rst few months of life with hy-
ponatremia and adrenal crisis.8
Prenatal molecular genetic diagnosis of CLAH might be
effective in Korean or Japanese families with the known
StAR mutations, as well as in families with a 46,XY karyo-
type but female genitalia on ultrasound and/or low maternal
serum estriol levels, in order to prevent future neonatal
deaths due to undiagnosed CLAH. Further prospective stud-
ies with larger populations are needed to determine whether
this would be useful.
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DISCUSSION
The maternal screening test during the second trimester is a
combined serum analysis for the prenatal detection of
Down syndrome, Edward syndrome, Patau syndrome, and
open neural-tube defects.8 The screening test measures the
levels of AFP, hCG, unconjugated estriol, and inhibin A.
Interestingly, this case showed low levels of AFP and
hCG, with very low levels of unconjugated estriol. The most
common cause of extremely low estriol levels is steroid sul-
fatase deciency, the prenatal manifestation of X-linked re-
cessive ichthyosis, which affects 1 in 3,000 males, and SLO
syndrome, which affects 1 in 15,000 to 20,000 and is caused
by mutations in the gene encoding 7-dehydrocholesterol re-
ductase (DHCR7).9-11 These two conditions need to be ruled
out by checking the levels of steroid sulfatase activity in the
amniotic cell culture and amniotic-uid DHCR7, respective-
ly. When there is no evidence of maternal virilization dur-
ing pregnancy, as in our case, it is unlikely suspicious of
placental aromatase deciency.12
During pregnancy, estriol is derived almost exclusively
from placental aromatization of the fetal adrenal steroid de-
hydroepiandrosterone sulfate (DHEAS). Therefore, low es-
triol levels in the context of normal fetal sonography and
growth should raise suspicion of decient fetal steroidogen-
esis, which results in decreased production of adrenal
DHEAS.9-11 Fetal adrenal insufciency can be caused by a
mutation in the gene encoding the StAR protein. The role of
StAR protein is facilitating transport of cholesterol into the
mitochondria and the mutation in the gene encoding this
protein results in lipoid adrenal hypoplasia or 17-hydroxy-
lase deciency.1,13,14 Although these entities are associated
with XY gender reversal, our case was a female and there
were no abnormal ndings of the genitalia upon prenatal
and postnatal examination. Other possibilities include X-
linked congenital adrenal hypoplasia, resistance to ACTH,
and secondary adrenal insufficiency, either isolated or as
part of multiple pituitary hormone deciency.15-17 Our ob-
servation of extremely low estriol levels during pregnancy
as a predictor of CLAH suggests that each case of extreme-
ly low estriol detected by the maternal screening test should

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