COMPLETE SEX REVERSAL: SRY POSITIVE 46,XX MALE BY

Y TO X TRANSLOCATION
#
C. Procopiuc
1*
; C. Dumitrescu
1
, C. Chirita
1
, M. Carsote
2
, A. Caragheorgheopol
1
,
A. Goldstein
1
, C. Poiana
1,2
1
"C. I. Parhon" National Institute of Endocrinology, Bucharest, Romania
2
"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
Abstract
Individuals with male phenotypes and 46 XX karyotype appear in about 1 of 20,000 births
with clinical features varying from normal male appearance to sexual ambiguity and
hermaphroditism. More than 80% of these patients present a spontaneous translocation of the
SRY gene from the Y to the X chromosome in the paternal germinal cells.
We present a case of a 2 years old boy diagnosed with minor hypospadias, bifid scrotum,
normal penis and palpable gonads in the scrotum. The karyotype is 46 XX and FISH analysis
reveals SRY translocation on one of the X chromosomes. Ultrasound exam does not reveal any
mullerian structures and a hCG test proves the testes to be functional. A short course of
treatment with hCG is recommended in order to induce the proper development of the scotal
sac. The patient will need monitoring, in order to identify the development of hypergonadic
hypogonadism, which characterizes such patients in later life. This case underlines the
importance of comprehensively investigating any patient with even minor genitalia anomalies.
Key words: 46,XX male, SRY, tranlocation, 46,XX testicular DSD.
INTRODUCTION
Discrepancy between genotype and phenotype of an individual give rise to the
sex reversal syndromes. The frequency of 46XX males is about 1:20.000 live birth.
Most of these cases are caused by the translocation of the SRY genes to an X
chromosome, but some are SRY negative, determined by duplications of SOX9,
22q or RSPO1 defects or gonadal mosaicism (1, 2). Usually these patients are
discovered as adults because of almost normal phenotype (abnormalities include
smaller height, gynaecomastia) and diagnosis is postponed until infertility and
hypergonadic hypogonadism develop. Some cases present with various degrees of
sexual ambiguity or hermaphroditism, probably because of skewed X inactivation
(3) and are diagnosed sooner. This is such a case.
525
Case Report
doi: 10.4183/aeb.2009.525
*Correspondence to: Camelia Procopiuc, MD, Department of Pediatric Endocrinology, "C.I. Parhon"
National Institute of Endocrinology, Bucharest, Romania, email: procopiuc_camelia@yahoo.com
# The data have been partially presented as a poster at the 4
th
National Congress of
Neuroendocrinology, 23-26 May 2009 Bucharest
Acta Endocrinologica (Buc), vol. V, no.4 , p. 525-531, 2009
CASE REPORT
We present the case of a 2 years old boy who was referred to our clinic for
discrete malformations at the level of the external genitalia. The parents gave their
informed consent for the medical procedures. The family and personal history were
unremarkable. He was the first child, born out of an uncomplicated pegnancy, at 38
weeks, from unrelated parents. The length at birth was 50 cm and the weight of
3200 grams. No genital malformations were noted at that moment.
Upon admission, the standing up height was 85.4 cm (-0.6 SD), and his weight
12.8 kg (normal for age). The height is normal for his age and corresponding with
the mid parental target height. The clinical exam was normal with the exception of
a frust hypospadias and a slightly bifid scrotum with a accentuated perineal raphe.
The penis length was normal (approx 4 cm). Firm gonads with a volume of around
1.5 ml each were palpable in the scrotal sacs, but had a tendency of ascending in the
inguinal canal. No vaginal opening, excess hair or other abnormalities of the area
were noted (Fig. 1).
The hormonal panel was normal, with undetectable levels of testosterone and
gonadotrophs, normal thyroid and adrenal function (Table 1). The ultrasound exam
did not show any internal gonads or uterus. At the level of the scrotum normal
homogenous testes were visible. The X Ray exam of the left hand showed a bone
age of two years (Fig. 2).
Chromosome analysis showed a 46 XX karyotype. Fluorescence in situ
hybridization (FISH) showed the SRY fragment of the Y chromosome translocated
on the short arm of one of the chromosomes X (Figs. 3 a,b). For marking the X
chromosome a CEPX probe directed against the centromeric region was used,
combined with a SRY probe. In order to establish the functionality of the gonads, a
human chorionic gonadotropin (hCG) test (with 100 U/kg of body weight of hCG
injected i.m - total dose of 1300 U) was performed. After three days, testosterone
levels had increased to 1.86 ng/ml, proving that the testes were functional.
Treatment with hCG, 6 doses of 500 U every third day was initiated to ensure
the complete descendence of the testis and the proper development of the scrotal sac
with favorable results. Because of the almost normal male phenotype and the male
psycho-social development until that age, the sex assignment as male was maintained.
DISCUSSION
Sex reversal syndromes are a part of the large group of disorders of sexual
differentiation. They are defined by the discordance between the phenotype of the
individual and the sexual pattern of his chromosomes There are two variants, one in
which the 46 XY individuals have a female phenotype, either because of a dysfunction
at the level of the Y chromosome or because of hormonal anomalies, Leydig cell
agenesia, androgen resistance syndrome or alterations in the synthesis of testosterone).
C. Procopiuc et al
526
Until now, around 300 patients with male phenotype but 46 XX karyotype
have been described since the first case was diagnosed in 1964, most of them as
individual cases (4,5). Between 80% and 90 % of the 46XX males have a
translocation of the SRY region of the short arm of the Y chromosome, usually to
the long arm of the chromosome X. Translocation of SRY to autosomes is very rare,
but cases have been described in which the SRY was located on chromosome 16 (6)
or 1 (1). The rest of the 46 XX males, in which no chromosome Y fragment could
be identified, are probably caused by up-regulating mutations or duplication of
autosomal genes involved in the development of the testis, like SOX9 on
chromosome 17 (1, 2). Other possible causes include a 46 XX/46XY mosaicism,
with the Y present only at the level of the gonads or an inactivation of a testis
repressor gene at the level of the X chromosome (7). The incidence was considered
around 1:100,000 live births, but more recent studies have found a higher frequence
of about 1:20,000 (8, 9).
SRY positive 46,XX male
527
Parameters Achieved values Normal ranges
Testosterone (ng/mL) nd <0.12
FSH (UI/L) nd <1.92
LH (UI/L) nd <1.03
Estradiol (pg/mL) nd <10
TSH (UI/mL) 1.53 0.45-4.5
17OH Prog (ng/dL) 53 <80
DHEAS (g/dL) 7 <40
Table 1. Hormonal profile
Figure 1. Clinical aspect: bifid scrotum with an
accentuated perineal raphe. Gonads palpable in the
scrotal sacs.
Figure 2. X Ray of the left hand: bone
age of 2 years.
SRY is an introneless gene that encodes a 204 amino-acid protein belonging to
the high mobility group (HMG) - box DNA bindings protein. It cooperates with SF1
and SOX 9, acting before them, determining male pattern sexual differentiation (10).
In the mouse embryo, it is active before and during testicular differentiation, between
10.5 and 12.5 days, determining the specialization of supporting cells at the level of
the embryonic genital ridge into Sertoli cells (11). No external factors, like toxins, or
infections have been described to increase the incidence of such mutations.
Usually SRY-positive individuals have normal or almost normal gonads and
phenotype, like in our case, compared with the more severe phenotype seen in SRY-
negative 46XX males which are frequently born with sexual ambiguity (8). In a
normal 46XX female, in every cell, one of the X chromosomes becomes randomly
inactive. In 46XX males, it seems that the SRY bearing X chromosome remains
preferentially active and the maternal X chromosome becomes inactive. This is
important in inducing complete masculinization rather than hermaphroditism (12) and
this is more important to the final phenotype than the length of the translocated
fragment (3). In a study on 10 SRY+, 46XX males, 7 presented preferential
inactivation of the normal X chromosome, possibly connected to the presence of
translocated gene (5). But other studies suggest that disruption of the normal SRY
function because of position effect is responsible for incomplete masculinisation (13).
Some patients, like the case we presented, are diagnosed in infancy or at birth
because of sexual ambiguity. Those that escape detection present later in life for
infertility without erectile dysfunction. The clinical picture includes short stature for
C. Procopiuc et al
528
Figure 3a: Two nuclei in
interphase, the green CEPX
probe corresponds to the X
chromosome (1) and the orange
probe marks the SRY region (2)
Figure 3b: A metaphasic
nucleus. The green CEPX probe
marks the X chromosomes (1)
and the orange probes reveals
the SRY region translocated on
one of the X chromosome (2),
magnified in detail.
a
b
a male but in the high normal range for a female, with normal body proportions.
This has raised the question of an yet unidentified growth factor related to the Y
chromosome, but outside the SRY region (5) Also present are small and soft testes
but with normal penis (2,14,15). Gynaecomastia is also common, and the
association with breast carcinoma has been described (16). No other malformations
or mental retardation have been described. Further investigations commonly reveal
azoospermia and hypergonadic hypogonadism, developing after puberty (5, 14, 15).
In one case, biopsy of the testes showed a Sertoli Only Cell syndrome (12). When
hypogonadism develops, hormonal replacement therapy should be started, in order
to prevent the adverse effects of hormonal imbalance.
A case of intratubular undifferentiated germ cell neoplasia in a SRY+, 46XX
male with descended testes has been described, so patients need life long
monitoring (17). Prenatal diagnosis has been described when ultrasound exam
showed male genitalia and amniocentesis revealed a 46 XX karyotype (8, 18).
The dynamic test with human corionic gonadotropin is used for assessing the
Leydig cell function of producing testosterone. The dose of hGC may vary, and also
the cut off for the increase of testosterone. The usual protocol consists of 1500 U /m
2
body surface of hCG injected i.m. and repeated after 72 hours. Testosterone is
measured at the beginning of the test, after 3 and 6 days. A normal response consists
of an increase of more than 100% in the levels of testosterone on the third day and a
300% increase on the sixth day, with a ratio of testosterone to dihydrotestosterone of
less than 10:1 (19). Another protocol consists of three doses of hCG of 1000 or 1500
U on alternative days, with a normal response implying an increase of testosterone
to over 1.70 ng/mL 48 hours after the first injection and to over 2.00 ng/mL after the
last injection (20). This is the protocol we used in the case of our patient.
The effect of hCG on the Leydig cells is used not only in diagnosis, but also
as therapy, to induce descent of the cryptorchis testes. Sometimes it is the only
treatment or it is used to facilitate orchidopexy. The total success rate was reported
initially between 15 and 60% (21). Some authors found the therapy more efficient
in younger children (22), but this was not confirmed (23). The position of the testes
influences the rate of success. Recent data are not so optimistic. A recent Swedish
meta-analysis indicated an efficacity for the hormonal therapy of only 15-20%, with
a later relapse in about one-fifth of the cases. This is associated with a possibility of
future negative impact on spermatogenesis because of increased apoptosis of germ
cells (21). Regarding the dosage, there are different protocols. For example, in a
study on 100 children with a final success rate of 30.2 %, the total doses used were
of 5000 U for children younger than 6 years and of 10000 for older patients (22).
CONCLUSIONS
Complete sex reversal is a challenging medical issue, requiring cooperation from
the fields of endocrinology, pediatrics, urology as well as psychiatry. The genetic
SRY positive 46,XX male
529
mechanism involved varies amongst cases and is an unique window into the normal
sex differentiation. Practitioners should be aware of the possibility of a 46 XX
karyotype in a male phenotype and that the real incidence is not well established,
because of lack of proper diagnosis. Interestingly, the SRY translocation has not been
connected so far with paternal trauma or infections, but more data are necessary. Our
case represents a situation when the diagnosis was established at an early enough age,
in order to permit therapy with hCG.
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