Genotype, Mortality, Morbidity, and Outcomes of 3β-Hydroxysteroid Dehydrogenase Deficiency in Algeria

Abstract

Background: 3β-hydroxysteroid dehydrogenase 2 (3βHSD2) deficiency is a rare form of congenital adrenal hyperplasia (CAH), with fewer than 200 cases reported in the world literature and few data on outcomes.

Patients and methods: We report a mixed longitudinal and cross-sectional study from a single Algerian center between 2007 and 2021. Virilization and under-masculinization were assessed using Prader staging and the external masculinization score (EMS), pubertal development staged according to the system of Tanner. Adrenal steroids were measured using mass spectrophotometry (LC-MS/MS). A genetic analysis of HSD3B2 was performed using Sanger sequencing.

Results: A 3βHSD2 defect was confirmed in 6 males and 8 females from 10 families (8 consanguineous), with p.Pro222Gln mutation in all but two siblings with a novel deletion: c.453_464del or p.(Thr152_Pro155del). Probable 3βHSD2 deficiency was diagnosed retrospectively in a further 6 siblings who died, and in two patients from two other centers. In the genetically confirmed patients, the median (range) age at presentation was 20 (0-390) days, with salt-wasting (n = 14) and genital anomaly (n = 10). The Prader stage for female patients was 2 (1-2) with no posterior fusion of the labia. The EMS for males was 6 (3-9). Median (range) values at diagnosis for 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEA-S), and 17-hydroxypregnenolone (17OHPreg) were elevated: 73.7 (0.37-164.3) nmol/L; 501.2(9.4-5441.3) nmol/L, and 139.7 (10.9-1500) nmol/l (NB >90 nmol/L diagnostic of 3βHSD2 defect). Premature pubarche was observed in four patients (3F:1M). Six patients (5F:1M) entered puberty spontaneously, aged 11 (5-13) years in 5 girls and 11.5 years in one boy. Testicular adrenal rest tumors were found in three boys. Four girls reached menarche at 14.3 (11-14.5) years, with three developing adrenal masses (surgically excised in two) and polycystic ovary syndrome (PCOS), with radiological evidence of ovarian adrenal rest tumor in one. The median IQ was 90 (43-105), >100 in only two patients and <70 in three.

Conclusions: The prevalence of 3βHSD2 deficiency in Algeria appears high, with p.Pro222Gln being the most frequent mutation. Mortality is also high, with significant morbidity from adrenal tumors and PCOS in adolescence and an increased risk of learning disability. The finding of adrenal tumors in older patients with 3βHSD2 indicates under-replacement, requiring effective hydrocortisone and fludrocortisone treatment rather than surgical removal.

Keywords: 3-β hydroxysteroid dehydrogenase deficiency; 3βHSD2; HSD3B2; adrenal rest tumors; congenital adrenal hyperplasia; newborn screening; polycystic ovary syndrome.

Figure 1

Family tree of 10 Algerian families (8 consanguineous) with a) 3βHSD2 deficiency (individuals shown as hatched circles or squares); and b) an unclassified severe learning disability syndrome (affected individuals shown as speckled circles or squares). A HSD3B2: p.Pro222Gln mutation was found in 9 families (diagonal hatching), while Family B shows a novel HSD3B2: p.Thr152_Pro155del mutation (horizontal hatching). Of 42 children born to the 10 families, 3βHSD2 deficiency was genetically proven in 18 (2 deaths) and suspected on clinical grounds in twins from Family E with neonatal death from salt-wasting.

Figure 2

(A–C) Appearance of external genitalia in two siblings from family E with 3βHSD2 deficiency due to a p.P222Q mutation, showing virilization with clitoromegaly and pubic hair in the sister, E II-8 (A) and under-masculinisation in the brother, EII-9 (B, C).

Figure 3

Characteristics of the p.P222Q mutation of the HSD3B2 gene [From Moisan et al, 1999 (27)] —reproduced by kind permission of Oxford University Press).

Figure 4

(A, B) Abdominal MRI scan in a 16-year-old with 3βHSD2 deficiency (Patient B II-1). Axial and coronal sections demonstrate a large left-sided adrenal tumor measuring 63 × 52 × 51 mm. The lesion shows central cystic degeneration and is pushing the kidney downwards. RK, right kidney; LK, left kidney; S, spleen; AT, adrenal tumor.

Figure 5

(A–C) Histology of adrenal tumor from patient G II-1 following surgical removal showing (A) fibrous capsule with an underlying neoplasm containing hemorrhagic foci, no vascular or capsular invasion; (B) tumor composed of cells arranged in nests and cords separated by vasculature and lymphoid tissue; and (C) higher magnification showing that the cells have distinct boundaries and clear cytoplasm with monomorphic nuclei and foci of oncocytic metaplasia. There is hyperchromasia of the nuclei and apoptosis. C, capsule; H, hemorrhagic focus; CNI, cords, nests and islands of tumor.