Clinical Characteristics, Cytogenetic and Molecular Findings in Patients with Disorders of Sex Development

The clinical characteristics of patients with disorders of sex development（DSD）, and the diagnostic values of classic cytogenetic and molecular genetic assays for DSD were investigated. In the enrolled 56 cases, there were 9 cases of 46,XY DSD, 6 cases of Turner syndrome（TS）, one case of Super female syndrome, 25 cases of Klinefelter syndrome, 14 cases of 46,XX DSD, and one case of autosomal balanced rearrangements with hypospadias. The diagnosis of sex was made through physical examination, cytogenetic assay, ultrasonography, gonadal biopsy and hormonal analysis. PCR was used to detect SRY, ZFX, ZFY, DYZ3 and DYZ1 loci on Y and X chromosomes respectively. The DSD patients with the same category had similar clinical characteristics. The karyotypes in peripheral blood lymphocytes of all patients were identified. PCR-based analysis showed presence or absence of the X/Y-linked loci in several cases. Of the 9 cases of 46,XY DSD, 6 were positive for SRY, 9 for ZFX/ZFY, 9 for DYZ3 and 8 for DYZ1 loci. Of the 6 cases of TS, only 1 case with the karyotype of 45,X,/46,XX/46,XY was positive for all 5 loci. Of the 25 cases of Klinefelter syndrome, all were positive for all 5 loci. In one case of rare Klinefelter syndrome variants azoospermia factor（AZF） gene detection revealed the loss of the AZFa＋AZFb region. In 14 cases of 46,XX DSD, 7 cases were positive for SRY, 14 for ZFX, 7 for ZFY, 7 for ZYZ3, and 5 for DYZ1. PCR can complement and also confirm cytogenetic studies in the diagnosis of sex in cases of DSD.

Epididymis cell atlas in a patient with a sex development disorder and a novel NR5A1 gene mutation

This study aims to characterize the cell atlas of the epididymis derived from a 46,XY disorders of sex development(DSD)patient with a novel heterozygous mutation of the nuclear receptor subfamily 5 group A member 1(NR5A1)gene.Next-generation sequencing found a heterozygous c.124C>G mutation in NR5A1 that resulted in a p.Q42E missense mutation in the conserved DNA-binding domain of NR5A1.The patient demonstrated feminization of external genitalia and Tanner stage 1 breast development.The surgical procedure revealed a morphologically normal epididymis and vas deferens but a dysplastic testis.Microfluidic-based single-cell RNA sequencing(scRNA-seq)analysis found that the fibroblast cells were significantly increased(approximately 46.5%),whereas the number of main epididymal epithelial cells(approximately 9.2%),such as principal cells and basal cells,was dramatically decreased.Bioinformatics analysis of cell–cell communications and gene regulatory networks at the single-cell level inferred that epididymal epithelial cell loss and fibroblast occupation are associated with the epithelial-to-mesenchymal transition(EMT)process.The present study provides a cell atlas of the epididymis of a patient with 46,XY DSD and serves as an important resource for understanding the pathophysiology of DSD.

Physical assessment and reference growth curves for children with 46,XY disorders of sex development

Importance:Impaired growth is an important factor in patients with disorders of sex development(DSD).Objective:To profile the growth of children with 46,XY DSD.Methods:We compared heights between 46,XY DSD children and normal boys and obtained growth curves for DSD using the k-median coefficient of variation method.The study subjects were categorized into groups with good response and poor response to the human chorionic gonadotrophin(HCG)test according to testosterone levels and were compared height standard deviation scores(HtSDS)with normal boys.Results:A total of 571 children with noncongenital adrenal hyperplasia(CAH)46,XY DSD were enrolled in this study.The overall HtSDS for the DSD subjects were 0.031 1.202.The HtSDS of DSD boys were lower than those for normal boys among multiple age groups since early infancy.In children aged≥12 years,the HtSDS values were significantly lower than the normal reference values for boys of the same age in both the good and poor response groups(P=.025 and P=.003,respectively).The HtSDS in the poor response group was generally lower than the normal reference value(P=.017).The average HtSDS values in the poor response groups were lower than those in the good response groups across multiple age groups.Interpretation:Growth retardation was evident in boys with non-CAH 46,XY DSD in early childhood and puberty.The level of growth retardation was related to testosterone level.DSD-specific growth curves can improve our understanding of growth dynamics and minimize the scope for bias in the assessment of growth in these children.

Prevalence of gene mutations in a Chinese 46,XY disorders of sex development cohort detected by targeted next-generation sequencing

46,XY disorders of sex development(DSD)is characterized by incomplete masculinization genitalia,with gonadal dysplasia and with/without the presence of Mullerian structures.At least 30 genes related to 46,XY DSD have been found.However,the clinical phenotypes of patients with different gene mutations overlap,and accurate diagnosis relies on gene sequencing technology.Therefore,this study aims to determine the prevalence of pathogenic mutations in a Chinese cohort with 46,XY DSD by the targeted nextgeneration sequencing(NGS)technology.Eighty-seven 46,XY DSD patients were enrolled from the Peking Union Medical College Hospital(Beijing,China).A total of fifty-four rare variants were identified in 60 patients with 46,XY DSD.The incidence of these rare variants was approximately 69.0%(60/87).Twenty-five novel variants and 29 reported variants were identified.Based on the American College of Medical Genetics and Genomics(ACMG)guidelines,thirty-three variants were classified as pathogenic or likely pathogenic variants and 21 variants were assessed as variants of uncertain significance.The overall diagnostic rate was about 42.5%based on the pathogenic and likely pathogenic variants.Androgen receptor{AR),steroid 5-alpha-reductase 2(SRD5A2)and nuclear receptor subfamily 5 Group A member 1(NR5A1)gene variants were identified in 21,13 and 13 patients,respectively.The incidence of these three gene variants was about 78.3%(47/60)in patients with rare variants.It is concluded that targeted NGS is an effective method to detect pathogenic mutations in 46,XY DSD patients and AR,SRD5A2,and NR5A1 genes were the most common pathogenic genes in our cohort.

Management of children with disorders of sex development:20-year experience in southern Thailand

Background:Disorders of sex development(DSD)is a group of sexual differentiation disorders resulting in genital anomalies with defects in gonadal hormone synthesis and/or incomplete genital development.These conditions result in problems concerning the sex assignment of the child.This study aims to describe the clinical features,diagnosis and management of children with DSD in southern Thailand.Methods:The medical records of 117 pediatric patients diagnosed with DSD during the period of 1991-2011 were retrospectively reviewed.Results:Disorders of sex development were categorized into 3 groups:sex chromosome abnormalities(53.0%),46,XX DSD(29.9%)and 46,XY DSD(17.1%).The two most common etiologies of DSD were Turner syndrome(36.8%)and congenital adrenal hyperplasia(29.9%).Ambiguous genitalia/intersex was the main problem in 46,XX DSD(94%)and 46,XY DSD(100%).Sex reassignment was done in 5 children(4.3%)at age of 3-5 years:from male to female in 4 children(1 patient with congenital adrenal hyperplasia,1 patient with 45,X/46,XY DSD,and 2 patients with 46,XX ovotesticular DSD)and from female to male in 1 patient with 46,XX ovotesticular DSD.Of the total 20 children with 46,XY DSD,16(80%)were raised as females.Conclusion:Management of DSD children has many aspects of concern.Sex assignment/reassignment depends on the phenotype(phallus size)of the external genitalia rather than the sex chromosome.

Complete androgen insensitivity syndrome caused by the c.2678C>T mutation in the androgen receptor gene:A case report

BACKGROUND Androgen insensitivity syndrome is an X-linked recessive genetic disease caused by mutations in the androgen receptor gene(AR).However,the underlying molecular mechanisms for the majority of AR variants remain unclear.In this study,we identified a point variant in three patients with complete androgen insensitivity syndrome(CAIS),summarized the correlation analysis,and performed a literature review.CASE SUMMARY The proband was raised as a girl.In infancy,she was first referred to hospital with a right inguinal hernia.Ultrasonography revealed the absence of a uterus and ovaries,and a testis-like structure located at the inguinal canal.Further diagnostic workup detected a 46,XY karyotype,and fluorescence in situ hybridization analysis showed the presence of the SRY gene.Histological analysis revealed the excised tissue to be testicular.Twelve years later,she was admitted to our hospital with a lack of breast development.Her pubic hair and breasts were Tanner stage I.She had normal female external genitalia.Blood hormone tests showed normal testosterone levels,low estradiol levels,and high gonadotropin levels.Her two siblings underwent similar examinations,and all three had a rare hemizygous missense mutation in AR:c.2678C>T.In vitro functional analyses revealed decreased nuclear translocation in AR-c.2678C>T mutation cells.CONCLUSION This case of CAIS was caused by an AR variant(c.2678C>T).Functional studies showed impaired nuclear translocation ability of the mutant protein.

Efficacy of intelligent diagnosis with a dynamic uncertain causality graph model for rare disorders of sex development

Disorders of sex development(DSD)are a group of rare complex clinical syndromes with multiple etiologies.Distinguishing the various causes of DSD is quite difficult in clinical practice,even for senior general physicians because of the similar and atypical clinical manifestations of these conditions.In addition,DSD are difficult to diagnose because most primary doctors receive insufficient training for DSD.Delayed diagnoses and misdiagnoses are common for patients with DSD and lead to poor treatment and prognoses.On the basis of the principles and algorithms of dynamic uncertain causality graph(DUCG),a diagnosis model for DSD was jointly constructed by experts on DSD and engineers of artificial intelligence.“Chaining”inference algorithm and weighted logic operation mechanism were applied to guarantee the accuracy and efficiency of diagnostic reasoning under incomplete situations and uncertain information.Verification was performed using 153 selected clinical cases involving nine common DSD-related diseases and three causes other than DSD as the differential diagnosis.The model had an accuracy of 94.1%,which was significantly higher than that of interns and third-year residents.In conclusion,the DUCG model has broad application prospects as a computer-aided diagnostic tool for DSDrelated diseases.

Variant analysis of the chromodomain helicase dNA-binding protein 7 in pediatric disorders of sex development

Importance:This study investigated the role of the chromodomain helicase DNA-binding protein 7(CHD7)in disorders of sex development(DSD).Objective:We aimed to present the potential pathogenicity of CHD7 variants in pediatric patients with DSD.Methods:Choosing cases with CHD7 variants from DSD patients in Beijing Children’s Hospital to assess for the study.Prediction software tools were used to predict variant pathogenicity in these subjects.results:Among the 113 DSD patients,22 cases had CHD7 variants.Twenty-four different CHD7 variants were identified in the 22 DSD patients.Prediction software combined with ClinVar database information and their clinical manifestations revealed that,of the 18 patients with 46,XY DSD,two had CHARGE syndrome and two had Kallmann syndrome.Seven of the variants were highly categorized as“likely to be pathogenic”and seven as“suspected to be pathogenic”.Of the four patients with 46,XX DSD,three had ovotesticular DSD(c.305A>G,c.2788G>A,and c.3098G>A)and one had testicular DSD(c.2831G>A).Interpretation:A high frequency of CHD7 variants was found in the DSD patients,especially those with 46,XY DSD.Thus,the detection of a pathogenic CHD7 variant could suggest a diagnosis of hypogonadotropic hypogonadism for 46,XY DSD patients,but pre-pubescent patients should be reassessed in adolescence to confirm this diagnosis.This study also suggests that DNA sequencing could help to identify pre-pubescent DSD patients.Further data are required to determine the connection between CHD7 variants and sex-reversal in patients with 46,XX DSD,and the accumulation of these data is essential and necessary for DSD research.

Genetic Approaches for Sex Determination of Chinese Female with Male Pseudohermaphroditism

Male pseudohermaphroditism is a rare disorders of sex development(DSD)that is manifested by a female-like appearance or incompletely differentiated external genitalia in an individual with a Y chromosome.In this paper,we report our investigation of the case of a 33-year-old Chinese female who was diagnosed with a malignant mixed germ-cell tumor of the ovary.To confirm the sex of the female,we utilized genetic approaches to detect amelogenin and Y-STR loci.Y chromosome microdeletion was performed to identify existing deletions in the AZF regions and SRY.Chromosome karyotyping and whole-exome sequencing(WES)were then applied to reveal the deletion of sex chromosome segments and pathogenic variations in DNA sequences.Using DNA-STR genotyping,we detected both AMEL-X and AMEL-Y fragments.We also found haplotype Y-STR loci and detected all alleles.Furthermore,no microdeletion was detected in the AZF regions and SRY.The chromosome karyotyping was 46,XY.WES revealed a transversion mutation of 58T→C in the androgen receptor exon 1,which could be the pathogenic variant in this case of abnormal sexual development.Sex determination in forensic DNA typing is based on the amelogenin system.It is important that forensic biologists should master various genetic approaches to overcome the issue of gender ambiguity caused by DSDs.

Genotype-phenotype correlations,surgical selections,and postoperative complications of 5α-reductase 2 deficiency in 69 children with hypospadias

5α-reductase 2 deficiency prevents testosterone from being converted to dihydrotestosterone,which causes abnormal urogenital sinus development.The aim of this study was to analyze the relationship between genotype–phenotype,surgical selections,and postoperative complications of 5α-reductase 2-deficient patients with hypospadias.We retrospectively evaluated the medical records of patients who were diagnosed with 5α-reductase 2 deficiency after genetic testing in the Department of Endocrinology and underwent initial hypospadias surgery in the Department of Urology in Beijing Children’s Hospital,Capital Medical University(Beijing,China),from April 2007 to December 2021.A total of 69 patients were included in this study;the mean age at surgery was 34.1 months,and the average follow-up time was 54.1 months.Sixty children were treated with preoperative hormone stimulation(PHS)to promote penile growth.The average penis length and glans width were increased by 1.46 cm and 0.62 cm,respectively.The most frequent mutations were p.R227Q(39.1%,54/138),p.Q6^(*)(15.2%,21/138),p.G203S(12.3%,17/138),and p.R246Q(11.6%,16/138).In 64 patients who were followed up,43 had a one-stage operation and 21 had a staged operation,and there were significant differences in external masculinization score(EMS)(P=0.008)and the average number of operation required to cure(P<0.001)between one-stage and staged operations.PHS had a positive effect(P<0.001)on penile development.The p.R227Q mutation was associated with higher EMS and less severe hypospadias.One-stage surgery can be selected if conditions permit.The growth and development of children are acceptable in the long term,but penis growth remains unsatisfactory.Longterm complications of hypospadias should be considered during puberty.

46 XX karyotype during male fertility evaluation; case series and literature review

Forty-six XX disorder of sex development is an uncommon medical condition observed at times during the evaluation of a man＇s fertility. The following is a case series and literature review of phenotypically normal men diagnosed with this karyotype. Our goal is to comprehend the patients＇ clinical presentation as well as their laboratory results aiming to explore options available for their management. A formal literature review through PubMed and MEDLINE databases was performed using ＂46 XX man＂ as a word search. A total of 55 patients, including those conveyed in this article were diagnosed with a 46 XX karyotype during their fertility evaluation. The patients＇ mean age _＋ s.d. was 34 ＋ 10 years and their mean height ＋ s.d. was 166 ＋ 6.5 cm. Overall, they presented with hypergonadotropic hypogonadism. Sexual dysfunction, reduced hair distribution, and gynecomastia were reported in 20% （4120）, 25.8% （8/31）, and 42% （13131） of the patients, respectively. The SRYgene was detected in 36 （83.7%） and was absent in the remaining seven （16.3%） patients. We found that a multidisciplinary approach to management is preferred in 46 XX patients. Screening for remnants of the mullerian ducts and for malignant transformation in dysgenetic gonads is imperative. Hypogonadism should be addressed, while fertility options are in vitro fertilization with donor sperm or adoption.

Phenotypic and molecular characteristics of androgen insensitivity syndrome patients

Androgen insensitivity syndrome （AIS）, an X-linked recessive genetic disorder of sex development, is caused by mutations in the androgen receptor （AR） gene, and is characterized by partial or complete inability of specific tissues to respond to androgens in individuals with the 46,XY karyotype. This study aimed to investigate AR gene mutations and to characterize genotype-phenotype correlations. Ten patients from unrelated families, aged 2-31 years, were recruited in the study. Based on karyotype, altered hormone profile, and clinical manifestations, nine patients were preliminarily diagnosed with complete AIS and one with partial AIS. Genetic analysis of AR gene revealed the existence of 10 different mutations, of which five were novel （c.2112 C〉G[p.STO4R], c.2290T〉A[p.Y764N], c.2626C〉T[p.Q876X], c.933dupC[p.K313Qfs＊28], and c.1067delC[p.A356Efs＊123]）; the other five were previously reported （c.1789G〉A[p.A597T], c.2566C〉T[p.R856C], c.2668G〉A[p.V890M], c.2679C〉T[p.P893L], and c.1605C〉G[p.Y535X]）. Regarding the distribution of these mutations, 60.0% were clustered in the ligand-binding domain of AR gene. Exons 1 and 8 of AR gene each accounted for 30.0% （3/10） of all mutations. Most of the truncation mutations were in exon 1 and missense mutations were mainly located in exons 4-8. Our study expands the spectrum of AR gene mutations and confirms the usefulness of AR gene sequencing to support a diagnosis of AIS and to enable prenatal or antenatal screening.

Surgical management and molecular diagnosis of persistent Müllerian duct syndrome in Chinese patients

Persistent Müllerian duct syndrome(PMDS)is a rare clinically and genetically overlapping disorder caused by mutations in the anti-Müllerian hormone(AMH)gene or the anti-Müllerian hormone receptor type 2(AMHR2)gene.Affected individuals present uterus and tubes in normally virilized males and are discovered unexpectedly during other surgeries.Since it is rare and complex,a definitive clinical diagnosis can be missed,and there are no guidelines regarding how to deal with the uterus.In the present study,exome sequencing and Sanger verification were performed for causal variants in 12 PMDS patients.Preoperative diagnoses were made by positive exome sequencing in 8 patients.Of them,7 patients evoked on the basis of ultrasound indicating bilateral testes on the same side of the body.Twelve different AMH variants(2 frameshift/nonsense,1 deletion,8 missense,and 1 in-frame)in 9 patients and 6 different AMHR2 variants(5 missense and 1 splicing)in 3 patients were identified.Seven variants were classified as“pathogenic”or“likely pathogenic”,and 4 of them were novel.All but two patients with AMH defects showed low serum AMH concentrations,but all patients with AMHR2 defects showed elevated AMH levels.During surgery,an abnormal vas deferens was observed in half of the patients.Eight patients underwent orchidopexy with uterine preservation.Of them,2 patients presented complications including irreducible cryptorchidism,and 3 patients developed Müllerian remnant cysts.Three patients underwent subtotal hysterectomy.Of them,one patient had complication of injury to the vas deferens,and one had hemorrhage after operation.This is the first report of PMDS involving a large Chinese population.The present study not only expands the variation spectrum but also provides clinical experience about the management of the uterus.

S578N mutation of the androgen receptor in an adolescent with complete androgen insensitivity syndrome

Androgen insensitivity syndrome （AIS） was first .described by the American gynecologist Morris in 1953 and was mitially described＇in 82 patients, The syndrome was designated testicular feminization syndrome , because the testes produce hormones with estrogen-like actions. Clinical AIS manifestations include the appearance of normal female external genitalia without internal female genital organs.