alexa Test with 5 mcg ACTH for Diagnosis of Non-classic Congenital Adrenal Hyperplasia | OMICS International
ISSN: 2157-7536
Journal of Steroids & Hormonal Science
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Test with 5 mcg ACTH for Diagnosis of Non-classic Congenital Adrenal Hyperplasia

Chagay NB1*, Fadeyev VV2, Melnichenko GA3, Ivanova ON3, Bakulina EG4 and Kotelnikova NYu4

1Department of Endocrinology, Stavropol State Medical University, Stavropol, Russia

2Department of Endocrinology, I. M. Sechenov Firsst Moscow State Medical University, Moscow, Russia

3Endocrinology Research Centre, Moscow, Russia

4Center of Family Healthcare and Reproduction, Stavropol, Russia

*Corresponding Author:
Chagay NB
Department of Endocrinology, Stavropol State Medical University
Stavropol, Switzerland, Russia
Tel: +79624063171
E-mail: [email protected]

Received date: May 26, 2016; Accepted date: Aug 26, 2016; Published date: Aug 31, 2016

Citation: Chagay NB, Fadeyev VV, Melnichenko GA, Ivanova ON, Bakulina EG, et al. (2016) Test with 5 mcg ACTH for Diagnosis of Non-classic Congenital Adrenal Hyperplasia. J Steroids Horm Sci 7:181. doi:10.4172/2157-7536.1000181

Copyright: © 2016 Chagay NB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Steroids & Hormonal Science

Abstract

Background: Short test with 250 mcg corticotropin (Tetracosactide acetate, a substance of first 24 amino acids from 39-acid chain of endogenous ACTH) is a diagnostic standard of non-classic form of congenital adrenal hyperplasia (CAH). However, it is well known that morning ACTH levels in healthy people fluctuate between 10 and 60 pg/ml, and peak cortisol levels can be achieved with 1-24 ACTH dose of 1 mcg or 5 mcg. Objective: To study the sensitivity and specificity of the test with 5 mcg ACTH to diagnose non-classic form of congenital adrenal hyperplasia (NCAN). Materials and Methods: During from 2006 to 2011, we screened 435 women aged from 16 to 35 (25 (21; 29) years) for CAH after exclusion of neoplastic hyperandrogenism. Protocol of low-dose (5 mcg) and standard (250 mcg) 1-24 ACTH tests: Blood sampling for basal 17-OHP and cortisol levels; blood sampling for 17-OHP and cortisol at 30 and 60 minutes after 5 mcg or 250 mcg 1-24 ACTH stimulation. Molecular genetic analysis for most prevalent CYP21 mutations was performed using allele specific polymerase chain reaction. Results: Diagnosis of non-classic CAH with 21-hydroxylase deficiency was proved in 5.3% (23/435) of patients. Conclusion: Low dose test with Tetracosactide 5 mcg can identify 21-hydroxylase deficiency in patients with stimulated 17-OHP concentrations over 14 ng/ml. Test with Tetracosactide 5 mcg had sensitivity of 72.7% and specificity of 100% with positive prognostic value (+PV) of 100%, and negative prognostic value (-PV) of 89.3%.

Keywords

Nonclassic adrenal hyperplasia; Low dose test; ACTH

Introduction

Short test with 250 mcg corticotropin (Tetracosactide acetate, a substance of first 24 amino acids from 39-acid chain of endogenous adrenocorticotropic hormone (ACTH)) is a diagnostic standard of non-classic form of congenital adrenal hyperplasia (CAH). This ACTH dose results in serum ACTH concentrations of up to 2000 pg/ml. However, it is well known that morning ACTH levels in healthy people fluctuate between 10 and 60 pg/ml, and peak cortisol levels can be achieved with 1-24 ACTH dose of 1 mcg or 5 mcg [1]. Thus, standard ACTH tests may result in false-positive results due to over stimulation of adrenal glands.

Patients and Methods

During from 2006 to 2011, we screened 435 women aged from 16 to 35 (25 (21; 29) years) for CAH.

Study inclusion criteria were following:

1. Dermatological or biochemical signs of hyperandrogenism in women with normal gonadotropins anovulatory and ovulatory cycle.

2. Normal gonadotropins anovulatory infertility without symptoms of hyperandrogenism.

First group of patients comprises of 234 patient with clinically and/or biochemically established non-neoplastic hyperandrogenism; 201 women without hyperandrogenism were included in the second group. Ovulation absented in 75.2% (176/234) of hyperandrogenic women and in 85.6% (172/201) of patients without hyperandrogenism. In our study we also included some women with recurrent pregnancy loss (12 in first group and 29 in second group).

Serum levels of LH, FSH, prolactin, testosterone, sex-binding globulin (SBG), dehydroepiandrosterone sulfate (DHEA-S) and other hormones were evaluated by solid chemiluminiscence immunoassay (IMMULITE I-DPC, Beckman Coulter DxI). Bioactive testosterone (bioTs) concentration estimated by on-line calculator ISSAM [2] using SBG level, constant S� [albumin concentration 4.3 g/dl]. Androgens levels compared to age-matched healthy women: Ts (50.8 (38.0; 60.9) ng/l); bioTs (13.2 (9.5; 19.6) ng/dl); DHEA-S (228 (180; 310) mg/dl).

For differential diagnostic of non-classic CAH with 21-hydroxylase deficiency we performed low-dose (5 mcg) 1-24 ACTH test with Tetracosactide acetate solution (250 mcg per 1 ml, NOVARTIS, Switzerland). Immediately before the test, 1 ml Tetracosactide acetate solution (250 mcg) was diluted by 49 ml of 0.9% NaCl solution to get concentration of 1-24 ACTH of 5 mcg per 1 ml. For intravenous bolus 1 ml of the final solution (5 mcg 1-24 ACTH) injected with 4 ml of 0.9% NaCl solution. In 20 women, standard test with 250 mcg 1-24 ACTH was additionally needed for further diagnosis.

Protocol of low-dose (5 mcg) and standard (250 mcg) 1-24 ACTH tests:

1) Blood sampling for basal 17-��Рand cortisol levels.

2) Intravenous bolus of 5 mcg or 250 mcg 1-24-ACTH.

3) Blood sampling for 17-��Рand cortisol at 30 and 60 minutes after 1-24-ACTH stimulation.

Molecular genetic analysis (MGA) for most prevalent CYP21 mutations was performed using allele specific polymerase chain reaction [3].

For sensitivity and specificity analysis of low-dose ACTH test we compared results of low-dose (5 mcg) and standard (250 mcg) Tetracosactide tests with data of molecular genetic analysis for CYP21.

Statistical data analysis was run using software STATISTICA 6.0 and MedCalc Version 7.4.2.0. We used Shapiro-Wilk test to assess normality of distribution, and relevant t-test for comparison of two depending or non-depending samples. Descriptive non-parametrical statistics included Median (Me), Mean (M), standard deviation (SD), quartiles [25; 75] and Min-Max range. To compare quantitative parameters of non-related samples, Mann-Whitney (U) test was applied. Wilcoxon test (W) and Friedman variance analysis (F) was used when comparing two or more related samples. Kendall's coefficient of concordance (nonparametric correlation coefficient between two variables) was used to assess the relationship between multidimensional variables. Chi-squared test (χ²) was done to analyze difference in distribution of categorical parameters in two groups. Correlation between numerical parameters was tested by Spearman (r) and Kendall’s Tau criteria. Sensitivity, specificity and accuracy of 5 mcg 1-24 ACTH test were calculated using standard formulas. Significance level was chosen at p<0.05.

Results

Anovulation in women from both groups was diagnosed as abnormally prolonged menstrual cycle (over 35 days up to amenorrhea, Me=52 days) and/or negative ovulation tests in at least 5 cycles. In group 1 hyperandrogenism was proven clinically (at least 8 scores of Ferriman-Gallwey scale in 62.4% (146/234), acne in 29.5% (69/234) of patients) and biochemically (Table 1).

Group Ts (ng/dl)
�е (25; 75)
bioTs (ng/dl)
�е (25; 75)
17-��Р(ng/ml)
�е (25; 75)
DHEA-S (mg/dl)
�е (25; 75)
U-�� (p) HA+ vs
HA-
HA+
(n=234)
88.5
(68; 105)
27.9 (21.6; 33.5) 1.82 (1.27; 2.77)
Min 0.4
Max 89.6
245.0 (187; 347)
Min 46
Max 1000
bioTe
�=0.000
17-���=0.000042
DHEA-S
�=0.718456
HA-
(n=201)
56,6
(38.9; 64.9)
14,75 (9.8; 18.0) 1.43 (0.98; 2.2)
Min 0.2
Max 6.52
259.0 (185; 274)
Min 48
Max 518

Table 1: Adrenal corticosteroids levels in study groups before ACTH-5 mcg stimulation test.

According to New et al. [4] and Moran et al. [5], non-classical deficiency of 21-hydroxylase should be considered in patients with elevated 17-��Рlevels (basal as well as ACTH stimulated) >10 ng/ml.

In our study 17-Ð�Ð�Р after ACTH-stimulation ranged from 0.96 to 323.7 ng/ml (Me 3.29 (2.33; 4.79) ng/ml) at 30 minutes, and from 0.99 to 113.23 ng/ml (Me 3.62 (2.59; 5.86) ng/ml) at 60 min. In 81.8% (356/435) of patients maximal 17-Ð�Ð�Р response to ACTH stimulation occurred at 60 min (F-variance analysis χ2 - test for 0-30-60 min, Wtest for 30-60 min, Ñ�=0.000). Differences in changes of 17-Ð�Ð�Р concentrations reflects the clear dependence on the stimulation (Kendall's coefficient of concordance=0.77524; rank correlation mean (r)=0.77460), but not similar sensitivity to ACTH in one person. Therefore, one can get false-negative result if 17-Ð�Ð�Р is measured only at 60 min.

For the proper interpretation of the 5 mcg ACTH-test results in diagnostics of 21-hydroxylase deficiency we formulated two tasks:

1) To estimate diagnostic ratio of 17-��Рincrease.

2) To evaluate the relevance of absolute values of stimulated 17- ��Рlevels.

Diagnosis of non-classic CAH is probable

Only 2 patients (0.95%) with hyperandrogenism had basal 17-��Рlevel >10 ng/ml and stimulated levels >17 ng/ml. Twenty-five women (23-with hyperandrogenism and 2 without it), with basal 17-��Рconcentration between 2.58 ng/ml and 7 ng/ml showed four-fold increase in 17-OHP levels up to >10 ng/ml after stimulation with Tetracosactide 5 mcg: 18 patients had stimulated 17-��Рconcentrations >14 ng/ml, and 7 patients showed stimulated 17-��Рbetween 10 and 14 ng/ml. These results made the diagnosis of nonclassic CHA probable in 27 women.

Non-classic CAH is unlikely

To evaluate relevance of increase ratio BUT NOT absolute stimulated levels of 17-Ð�Ð�Р for the diagnostics of 21-hydroxylase deficiency, we compared increase rate of 17-Ð�Ð�Р and cortisol concentrations. Such approach prevents underestimation of maximal 17-Ð�Ð�Р concentrations <10-14 ng/ml due to «low dose» of ACTH.

We found that cortisol rises in significantly lower degree than 17- Ð�Ð�Р in response to 5 mcg Tetracosactide (variance analysis χ2 p<0.00000). There was a correlation between basal cortisol or 17-Ð�Ð�Р levels and elevation degree after stimulation with Tetracosactide-5 mcg (r=0.265034; Ñ�=0.000001 for cortisol; r=0.477788; Ñ�=0.0000 for 17- Ð�Ð�Р).

334 patients had less than 2.5-fold rise of 17-��Рlevels: 32 women (9.5%) reached 17-��Рmaximal concentrations of 4.0-6.2 ng/ml and other 332 women-under 4 ng/ml.

We suggested that 76.8% (n=334) patients with less than 2.5-fold 17-��Рincrease and maximal 17-��Рconcentrations <6.2 ng/ml were unlikely to have non-classic CAH. MGA of CYP21 -gene in 14 women with hirsutism and relatively high simulated 17-��Рlevels showed no mutations.

Test results are ambiguous and further standard test with 250 mcg of ACTH is needed for differential diagnosis of CAH

Further search for 21-hydroxilase deficiency was suggested in 48 patients with basal 17-��Р level over 1.7 ng/ml (recommended basal 17-��Р level for the diagnosis of 21- hydroxilase deficiency [5]) and documented >3-fold increase of 17-��Р.

According maximal stimulated 17-levels in the tests with low and standard 1-24 ACTH doses (5 mcg and 250 mcg Tetracosactide) we differentiated three different types of adrenal response:

-Dose-independent 87.5% (42/48)-differences of peak 17-��Рlevels are not significant;

-Dose-dependent 12.5% (6/48)-peak 17-��Рlevels between 6.7-7.3 ng/ml after low ACTH dose and >10 ng/ml after standard ACTH dose (Table 2).

Response to ACTH, M ± m 17-Ð�Ð�Р, basal, ng/ml 17-Ð�Ð�Р, ACTH 5 mcg 17-Ð�Ð�Р, ACTH 250 mcg
Dose-independent (n=42) 5. 4 (1.9; 9.6) 16.4 (7.3; 39.5) 19.3 (6.4; 44.4) *�=0.39
Dose-dependent (n=6) 2.99 ± 0.97 (CI 1.98; 4.01) 7.104 ± 1.35 (CI 5.69; 8.52) 17.306 ± 4. 7 (CI 12.36; 22.25) *Ñ�=0.0025

Table 2: Dose-independent and dose-dependent 17-��Рresponse to Tetracosactide 5 mcg and Tetracosactide 250 mcg.

There was a subgroup of patients (6/48 (12.5%)) with dose dependent adrenal response to ACTH who needed further search for non-classical ACH. All these 6 women had maximal stimulated 17- Ð�Ð�Р concentrations after 5 mcg Tetracosactide test ≥ 6.7 ng/ml and dermatological signs of hyperandrogenism (hirsutism).

Molecular genetic analysis of CYP21 gene

Twenty-seven patients had basal or stimulated 17-Ð�Ð�Р concentrations over 10 ng/ml, and 17 of them had molecular genetic analysis of CYP21 gene. Patients with stimulated 17-Ð�Ð�Р levels between 10 ng/ml and 14 ng/ml were found to be heterozygous carriers of most common CYP21 mutations. Women with maximal 17- Ð�Ð�Р levels ≥ 14 ng/ml had homozygous mutations or combinations of different heterozygous mutations (Table 3) (Figures 1 and 2).

Maximal simulated 17-��Рlevel Homozygous mutations or combinations of heterozygous mutations Carrier state of heterozygous mutations
NC-CAH is very likely
Test with ACTH 5 and 250 mcg:
10 ng/ml<17-��Р<14 ng/ml
(n=9)
Not found V281L
V281L
P30L
Q318X
I2 spl
V281L
V281L

Common mutations not found (n=2)
Test with ACTH 5 and 250 mcg:
17-��Р>14 ng/ml
(n=8)
V281L/V281L
V281L/V281L
V281L/V281L
V281L/V281L
P453S/P453S
I172N/V281L
I2 spl/V281L
V281L/V281L
Not found
NC-CAH is unlikely
Test with ACTH 5 mcg
17-��Р4-6.2 ng/ml (n=14)
Not found Not found
NC-CAH is ambiguous
Dose independent response
Test with ACTH 5 mcg
and Test with ACTH 250 mcg:
17-Ð�Ð�Р≥6,7 ng/ml (n=21)
Not found Not found
Dose-dependent response (n=3)
Test with ACTH 5 mcg:
6,7<17-��Р<10 ng/ml;
Test with ACTH 250 mcg:
10<17-��Р<14 ng/ml
Not found V281L
I2 spl
V281L
Test with ACTH 5 mcg (n=3):
6.7<17-��Р<10 ng/ml;
Test with ACTH 250 mcg:
17-��Р>14 ng/ml
V237E/V237E
V281L/V281L
Chimeric gene
Not found

Table 3: Results of molecular-genetic analysis of CYP21 gene.

steroids-hormonal-science-exons-gene-localization

Figure 1: Schematic representation of the exons of the gene and the localization point common mutations.

steroids-hormonal-science-Electrophoregrams-products

Figure 2: Electrophoregrams products allele-specific amplification with the mutation test I2 spl , P30L and I172N .

Molecular genetic analysis in 14 patients with maximal 17-��Рconcentrations between 4 and 6.2 ng/ml revealed no CYP21 mutations using allele-specific polymerase chain reaction (n=10) or direct CYP21 gene sequencing. Thus, 21-hydroxylase deficiency was excluded in these women. 334 women with non-significant 17-��Рrise (<6.2 ng/ml) did not need further investigation for the non-classical CAH and were excluded from the study. In other 320 patients 21- hydroxylase deficiency could be surely excluded only after either standard test with 250 mcg ACTH or direct CYP21 gene sequencing.

We found no CYP21 mutations in 21 patients with dose independent adrenal response to 5 mcg tetracosactide. There were 13 women with maximal 17-��Рconcentrations >6.7 ng/ml. However, non-classical CAH was not proved in them during standard test and allele specific PCR of CYP21 gene.

Molecular-genetic analysis in 6 women with dose-dependent response to Tetracosactide 5 mcg and Tetracosactide 250 mcg revealed 2 cases of homozygous CYP21 mutations: V281L /V281L [6], V237E / V237E and one case of chimera gene CYP21P /CYP21 [7] (Figure 3).

steroids-hormonal-science-chimeric-gene

Figure 3: Scheme of CYP21P /CYP21 chimeric gene with deletion of 30 bp.

Non-classical CAH was proved only in women with maximal 17- Ð�Ð�Р concentration ≥ 6.7 ng/ml after stimulation with 5 mcg Tetracosactide and >14 ng/ml after stimulation with 250 mcg tetracosactide.

Three patients with maximal 17-��Рlevels under 6.0 ng/ml after stimulation with 5 mcg Tetracosactide and under 10 ng/ml after 250 mcg Tetracosactide, had heterozygous carrier state of V281L mutation.

We evaluated sensitivity and specificity of the main hyperandrogenism symptoms, such as hirsutism and anovulation to define those women who need examination for 21-hydroxylase deficiency.

Hirsutism seems to be the main symptom which disturbs women with NC-CAH. However regular and ovalutary menstrual circle cannot rule out NC-CAH.

Sensitivity and specificity analysis of low-dose test with 1-24 ACTH-5 mcg included data from 36 patients who run through lowdose and standard ACTH test as well as genetic analysis of CYP21 . These were patients with 17-��Рconcentration over 14 ng/ml and homozygous or mixed heterozygous mutations of CYP21 gene. Other patients with heterozygous mutations and 17-��Рunder 14 ng/ml (n=10), and 2 patients with dose-independent reaction to ACTH, max 17-��Рlevel >7 ng/ml and no proven mutations of CYP21 gene (PCR) were excluded from this analysis. Unfortunately, 10 clinically hyperandrogenic patients and high Tetracosactide 5 mcg-stimulated 17-��Рlevels (over 14 ng/ml) withdrew from the study. This fact may have influenced the results of sensitivity analysis.

Test with Tetracosactide 5 mcg had sensitivity of 72.7% and specificity of 100% with positive prognostic value (+PV) of 100%, and negative prognostic value (-PV) of 89.3%.

According to the results of the test with 5 mcg Tetracosactide, absolute stimulated 17-��Рlevels but not grades of its increase are relevant for the diagnostics of 21-hydroxilase. Steroidal response to Tetracosactide may be dose dependent in 12.5% of patients, and they have higher peak 17-��Рlevels after stimulation with Tetracosactide-250 mcg. Lack of low-dose 1-24 ACTH stimulation can be probably explained by an adaptation of hyhperplase adrenal glands to grater pituitary stimuli.

Diagnosis of non-classic CAH with 21-hydroxylase deficiency was proved in 5.3% (23/435) of patients reported hirsutism and/or anovulation. 21-hydroxylase deficiency was verified in 8.5% (20/234) of hyperandrogenic patients and in 1.5% (3/201) of women without clinical signs and symptoms of hyperandrogenism.

Conclusion

1. Low dose test with Tetracosactide 5 mcg can identify 21- hydroxylase deficiency in patients with stimulated 17-��Рconcentrations over 14 ng/ml.

2. Standard stimulation test with Tetracosactide 250 mcg and MGA of CYP21 gene is indicated for patients with dermatological signs of hyperandrogenism and maximal 17-Ð�Ð�Р levels ≥ 6.7 ng/ml after stimulation with Tetracosactide 5 mcg.

It should be noted, that clinical relevance of mild non-classic CAH which cannot be detected with low-dose but not with standard-dose Tetracosactide test is still uncertain. It is also known, that most women with heterozygous mutation of CYP21 gene are symptoms free and have normal fertility. Further studies of the cased with discordant results of tests with Tetracosactide 5 mcg and 250 mcg may bring useful information.

Conflict of Interest and the Source of Funding

The authors deny financial support from the drug manufacturers. Conflict of interest in determining the structure of the study, in the collection, analysis and interpretation of missing data.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Recommended Conferences

Article Usage

  • Total views: 8322
  • [From(publication date):
    September-2016 - Dec 18, 2017]
  • Breakdown by view type
  • HTML page views : 8246
  • PDF downloads : 76
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

immu[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version