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Cited by 41Sexual Differentiation and DisordersAdrenal Hormones and DisordersMetabolism and Genetic Disorders

Relationship of CYP21A2 genotype and serum 17-hydroxyprogesterone and cortisol levels in a large cohort of Italian children with premature pubarche

Open access
Ghizzoni, Lucia, Cappa, Marco, Vottero, Alessandra, Ubertini, Graziamaria, Carta, Daniela, Di Iorgi, Natascia, Gasco, Valentina, Marchesi, Maddalena +7 more·2011·European Journal of Endocrinology
DOI 10.1530/eje-11-0119
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Abstract

Objective: Premature pubarche (PP) is the most frequent sign of nonclassic congenital adrenal hyperplasia (NCCAH) due to 21-hydroxylase deficiency in childhood. The aim of this study was to assess the relationship between the CYP21A2 genotype and baseline and ACTH-stimulated 17-hydroxyprogesterone (17-OHP) and cortisol serum levels in patients presenting with PP. Patients and methods: A total of 152 Italian children with PP were studied. Baseline and ACTH-stimulated 17-OHP and cortisol serum levels were measured and CYP21A2 gene was genotyped in all subjects. Results: Baseline and ACTH-stimulated serum 17-OHP levels were significantly higher in NCCAH patients than in both heterozygotes and children with idiopathic PP (IPP). Of the patient population, four NCCAH patients (7.3%) exhibited baseline 17-OHP values <2 ng/ml (6 nmol/l). An ACTH-stimulated 17-OHP cutoff level of 14 ng/ml (42 nmol/l) identified by the receiver-operating characteristics curves showed the best sensitivity (90.9%) and specificity (100%) in distinguishing NCCAH patients. This value, while correctly identifying all unaffected children, missed 9% of affected individuals. Cortisol response to ACTH stimulation was <18.2 μg/dl (500 nmol/l) in 14 NCCAH patients (28%) and none of the heterozygotes or IPP children. Among the 55 NCCAH patients, 54.5% were homozygous for mild CYP21A2 mutations, 41.8% were compound heterozygotes for one mild and one severe CYP21A2 gene mutations, and 3.6% had two severe CYP21A2 gene mutations. Conclusion: In children with PP, baseline 17-OHP levels are not useful to rule out the diagnosis of NCCAH, which is accomplished by means of ACTH testing only. The different percentages of severe and mild CYP21A2 gene mutations found in PP children compared with adult NCCAH patients is an indirect evidence that the enzyme defect is under-diagnosed in childhood, and it might not lead to the development of hyperandrogenic symptoms in adulthood. Stress-dose glucocorticoids should be considered in patients with suboptimal cortisol response to ACTH stimulation.

AI snapshot

Written from the paper’s full text.

TL;DR

In 152 Italian children with premature pubarche, NCCAH due to 21-hydroxylase deficiency was diagnosed by ACTH-stimulated 17-OHP, not baseline 17-OHP, and was associated with lower ACTH-stimulated cortisol in a subset. CYP21A2 genotypes in NCCAH children were predominantly mild/mild or mild/severe, suggesting under-diagnosis in childhood.

Key findings

  • Baseline and ACTH-stimulated 17-OHP were significantly higher in NCCAH patients (n=55) than in heterozygotes (n=50) and idiopathic PP children (n=47). Four NCCAH patients (7.3%) had baseline 17-OHP <2 ng/ml (6 nmol/l), so baseline levels could not rule out NCCAH.
  • An ACTH-stimulated 17-OHP cutoff of 14 ng/ml (42 nmol/l) had sensitivity 90.9% and specificity 100%, missing 9% of affected individuals; a cutoff of 10 ng/ml (30 nmol/l) had sensitivity 100% and specificity 86.2%.
  • Post-ACTH cortisol <18.2 µg/dl (500 nmol/l) occurred in 14 NCCAH patients (28%) and in none of the heterozygotes or IPP children. Post-ACTH cortisol was lower in NCCAH (22.03±7.63 µg/dl) than in heterozygotes (37.26±7.68 µg/dl) and IPP (34.54±6.35 µg/dl; P<0.0001).
  • Among 55 NCCAH patients, 52.7% had two mild CYP21A2 mutations, 41.9% were compound heterozygotes for one mild and one severe mutation, and 3.6% had two severe mutations; V281L was the most common mutation. Clinical features (chronological age, bone age, BA/CA, height SDS) did not differ significantly among groups.

Methods

  • Retrospective study of 152 unrelated Italian children (114 females, 38 males) with premature pubarche, selected from four institutions and grouped as IPP (n=47), heterozygotes (n=50), or NCCAH (n=55).
  • ACTH stimulation test used 250 µg ACTH(1-24) IV with blood sampling before and 60 min after for 17-OHP and cortisol by RIA; CYP21A2 was genotyped by direct sequencing, Southern blot, and MLPA.
  • Statistical analysis used Student’s t-test, one-way ANOVA with Bonferroni correction, ROC curves, and kappa index; P<0.05 was considered significant.

Limitations

  • No dedicated limitations section; the paper states that abnormal biochemical cortisol responses without clinical adrenal insufficiency are difficult to interpret and that cortisol need during stressful conditions is unknown, and that phenotype cannot always be predicted from genotype.
  • Evident: retrospective/random selection and a single Italian cohort may limit generalizability; functional characterization of novel mutations (M150R, R366H) was still under study.
  • Evident: no long-term follow-up for adrenal insufficiency or adult hyperandrogenism outcomes is reported.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1530/eje-11-0119

Cites

37 of 37 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 26 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Post-ACTH cortisol levels were significantly lower in NCCAH patients than in heterozygotes and IPP children (NCCAH: 22.03±7.63 μg/dl; heterozygotes: 37.26±7.68; IPP: 34.54±6.35; P<0.0001 ANOVA).

    “post-ACTH hormone levels were significantly lower in NCCAH patients compared with the other groups (NCCAH: 22.03G7.63mg/dl (607G210 nmol/l); heterozygotes: 37.26G7.68mg/dl (1028G212 nmol/l); IPP: 34.54G6.35mg/dl (953G175 nmol/l, P!0.0001 ANOVA)).”
    Quote in the paperSubstantial claim
  • Findingown data

    Post-ACTH 17-hydroxyprogesterone levels did not differ significantly between heterozygous subjects with severe mutations and those with mild mutations.

    “When the post-ACTH 17-OHP levels of heterozygous subjects with severe mutations were compared with those of subjects heterozygous for mild mutations, no significant differences were detected (Fig. 1).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The ACTH-stimulated 17-hydroxyprogesterone cutoff of 14 ng/ml (42 nmol/l) identified by ROC analysis had the best sensitivity, 90.9%, and specificity, 100%, for distinguishing NCCAH patients in the premature pubarche population.

    “An ACTHstimulated 17-OHP cutoff level of 14 ng/ml (42 nmol/l) identified by the receiver-operating characteristics curves showed the best sensitivity (90.9%) and specificity (100%) in distinguishing NCCAH patients.”
    • Also stated in: § Clinical and biochemical profile of patients · plain
      “Evaluation of the discriminating power of baseline and ACTH-stimulated 17-OHP values to make the diagnosis of NCCAH showed the best cutoffs, i.e. those with the best sensitivity and specificity, to be 2.82 ng/ml (8.5 nmol/l; sensitivity 84.1%, specificity 94.9%) and 14 ng/ml (42 nmol/l; sensitivity 90.9%, specificity 100%), respectively, in the whole population with PP.”
    Quote in the paperSubstantial claim
  • Findingown data

    Six IPP children and 12 heterozygotes had ACTH-stimulated 17-hydroxyprogesterone levels between 10 and 14 ng/ml (30 and 42 nmol/l).

    “Six IPP and 12 heterozygotes exhibited ACTH-stimulated 17-OHP levels between 10 and 14 ng/ml (30 and 42 nmol/l).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Four of the NCCAH patients, 7.3%, had baseline 17-hydroxyprogesterone values below 2 ng/ml (6 nmol/l).

    “Of the patient population, four NCCAH patients (7.3%) exhibited baseline 17-OHP values !2 ng/ml (6 nmol/l).”
    • Also stated in: § Clinical and biochemical profile of patients · plain
      “There were four NCCAH patients (7.3%) with baseline 17-OHP values !2 ng/ml (!6 nmol/l)”
    Quote in the paperNot a substantial claim
  • May combine two claims. 30
  • Classified as probably not a substantial claim. 11
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingown data

    Chronological age at symptom onset and first evaluation, bone age at first evaluation, bone age to chronological age ratio, and height SDS at first evaluation were similar across the IPP, heterozygote, and NCCAH groups.

    “CA at initiation of symptoms and at first evaluation, BA at first evaluation, BA to CA ratio (BA/CA), and height SDS at first evaluation were similar in the three groups of subjects.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based). May combine two claims.

    Findingown data

    The V281L mutation was the predominant mutation, found on 67.5% of mutated alleles and in 77.1% of children carrying at least one mutated allele.

    “The predominant mutation was V218L, which was found on 67.5% of mutated alleles and in 77.1% of children carrying at least one mutated allele.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    None of the NCCAH patients with suboptimal cortisol response to ACTH had ever reported illnesses consistent with adrenal insufficiency or had undergone minor or major surgery.

    “None of the NCCAH patients with suboptimal cortisol response to ACTH ever reported illnesses consistent with adrenal insufficiency or had undergone either minor or major surgery.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The most frequent mutations among heterozygous subjects were V281L (32 subjects, 64%) and Q318X (four subjects, 8%).

    “The most frequent mutations were V281L (32 subjects, 64% of heterozygotes) and Q318X (four subjects, 8%; Table 3).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    None of the IPP children or heterozygous subjects had a serum cortisol response to ACTH below 18.12 μg/dl (500 nmol/l), whereas 14 NCCAH patients did.

    “None of the IPP children or heterozygous subjects showed serum cortisol concentrations in response to ACTH stimulation !18.12 mg/dl (500 nmol/l), whereas 14 NCCAH patients exhibited post-ACTH hormone levels !18.12 mg/dl (500 nmol/l).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Cutoffs identifying 100% of affected children were 0.89 ng/ml (2.7 nmol/l) for baseline and 10 ng/ml (30 nmol/l) for stimulated 17-hydroxyprogesterone, with specificities of 46.2% and 86.2%, respectively.

    “The cutoffs able to identify 100% of affected children were 0.89 ng/ml (2.7 nmol/l) and 10 ng/ml (30 nmol/l) for baseline and stimulated 17-OHP levels, with a specificity of 46.2 and 86.2% respectively.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Among NCCAH patients, ACTH-stimulated 17-hydroxyprogesterone levels were between 10 and 15 ng/ml in six, between 15 and 25 ng/ml in 15, and above 25 ng/ml in 34.

    “ACTH-stimulated 17-OHP levels were between 10 and 15 ng/ml (30 and 45 nmol/l) in six patients, between 15 and 25 ng/ml (45 and 76 nmol/l) in 15 patients, and above 25 ng/ml (76 nmol/l) in the remaining 34 NCCAH patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among the 55 NCCAH patients, 52.7% had two mild CYP21A2 mutations, 41.9% were compound heterozygotes for one mild and one severe mutation, and 3.6% had two severe mutations.

    “Among the 55 children affected by NCCAH, 52.7% had two mild CYP21A2 gene mutations, 41.9% were compound heterozygotes for one mild and one severe CYP21A2 gene mutations, and 3.6% had two severe CYP21A2 gene mutations (Table 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The baseline and stimulated 17-hydroxyprogesterone cutoffs from ROC analysis failed to recognize six and five patients respectively as false negatives, and produced six and two false positives respectively.

    “Overall, the baseline and stimulated 17-OHP cutoff values identified by the ROC analysis failed to recognize six and five patients respectively (false negative), while the false positive subjects detected were six and two respectively (kappa index).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The highest baseline and post-ACTH 17-hydroxyprogesterone levels among unaffected subjects were 3 ng/ml (9 nmol/l) and 14 ng/ml (42 nmol/l), respectively.

    “The highest baseline and post-ACTH 17-OHP levels in these unaffected subjects were 3 ng/ml (9 nmol/l) and 14 ng/ml (42 nmol/l) respectively.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among the 50 heterozygous subjects, 36 (72%) carried a mild mutation and 13 (26%) carried a severe mutation.

    “Among the 50 heterozygous subjects, 36 carried a mild mutation (72%) and 13 (26%) a severe mutation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Areas under the ROC curves were 0.959 (95% CI 0.896-0.989) for baseline 17-hydroxyprogesterone and 0.990 (95% CI 0.938-0.998) for ACTH-stimulated 17-hydroxyprogesterone.

    “Areas under the ROC curves were 0.959% (95% confidence interval (CI)Z0.896-0.989)and 0.990% (95% CIZ0.938-0.998)for baseline and stimulated 17-OHP levels respectively.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The 14 ng/ml ACTH-stimulated 17-hydroxyprogesterone cutoff correctly identified all unaffected children but missed 9% of affected individuals.

    “This value, while correctly identifying all unaffected children, missed 9% of affected individuals.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    With cutoffs of 0.89 ng/ml for baseline and 10 ng/ml for stimulated 17-hydroxyprogesterone, all affected patients were detected, while 51 unaffected subjects with baseline values above 0.89 and 17 with stimulated values above 10 were identified as affected.

    “With such cutoffs, all patients were detected, while 51 unaffected subjects with baseline 17-OHP values O0.89 (O2.7 nmol/l) and 17 with stimulated 17-OHP values O10 (O30 nmol/l) were identified as affected (false positive; kappa index).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Cortisol response to ACTH stimulation was below 18.2 μg/dl (500 nmol/l) in 14 NCCAH patients (28%) and in none of the heterozygotes or children with idiopathic premature pubarche.

    “Cortisol response to ACTH stimulation was !18.2 mg/dl (500 nmol/l) in 14 NCCAH patients (28%) and none of the heterozygotes or IPP children.”
    • Also stated in: § Clinical and biochemical profile of patients · plain
      “None of the IPP children or heterozygous subjects showed serum cortisol concentrations in response to ACTH stimulation !18.12 mg/dl (500 nmol/l), whereas 14 NCCAH patients exhibited post-ACTH hormone levels !18.12 mg/dl (500 nmol/l).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Comparison of clinical and hormonal phenotypes between mild/mild and mild/severe genotypes revealed no differences, except baseline 17-OHP was significantly higher in mild/severe.

    “The comparison of the clinical and hormonal phenotype of the different genotypes revealed no differences between the mild/mild and mild/severe genotypes, except for baseline 17-OHP levels that were significantly higher in patents with mild/severe mutations.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The genotype classification (mild/mild, mild/severe, severe/severe) reflects the actual enzymatic severity.

  • May combine two claims.

    Findingown data

    A baseline 17-OHP threshold of 0.89 ng/ml (2.7 nmol/l) gave 100% sensitivity but only 46.2% specificity.

    “When we tried to optimize the sensitivity (100%) by using a baseline 17-OHP threshold level of 0.89 (2.7 nmol/l), the specificity was greatly reduced (46.2%)”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data

    Two patients in the cohort carrying two severe CYP21A2 mutations had a nonclassic phenotype.

    “The failure of strict correspondence of phenotype and genotype with the possibility of the former to be even milder than expected is also suggested by the two patients in our cohort carrying two severe mutations.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The genotype classification (mild/mild, mild/severe, severe/severe) reflects the actual enzymatic severity.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    A number of cases of premature pubarche are associated with NCCAH due to 21-hydroxylase deficiency, with reported incidence ranging from 0% to 40%.

    “A number of cases of PP are also associated with nonclassic congenital adrenal hyperplasia (NCCAH) due to 21-hydroxylase (21-OH) deficiency, with an incidence extremely variable, ranging from 0% in some reports to 40% in others, probably due to varying ethnic background and the use of different diagnostic criteria (5).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Diagnosis of NCCAH due to 21-hydroxylase deficiency is based on elevated baseline and ACTH-stimulated 17-hydroxyprogesterone levels.

    “The diagnosis is based on elevated baseline and ACTH-stimulated 17-hydroxyprogesterone (17-OHP) levels.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] source

      Not checked in the free run.

    • cites [9] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    In children with premature pubarche, baseline 17-hydroxyprogesterone levels are not useful to rule out NCCAH; diagnosis requires ACTH testing.

    “In children with PP, baseline 17-OHP levels are not useful to rule out the diagnosis of NCCAH, which is accomplished by means of ACTH testing only.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Baseline 17-hydroxyprogesterone levels above 5 ng/ml (15 nmol/l) and ACTH-stimulated values above 10 ng/ml (30 nmol/l) are the established cutoffs for diagnosing NCCAH.

    “Baseline 17-OHP levels O5 ng/ml (O15 nmol/l) and ACTH-stimulated 17-OHP values O10 ng/ml (O30 nmol/l) are the cutoffs established for the diagnosis of the disease (8,9).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] source

      Not checked in the free run.

    • cites [9] source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    A good correlation is generally observed between CYP21A2 genotype and clinical phenotype, although discrepancies have been reported, especially within intermediate severity groups, making phenotype prediction unreliable.

    “Generally, a good correlation is observed between CYP21A2 genotype and clinical phenotype, although some discrepancies have been reported especially within mutation groups of intermediate severity, making phenotype prediction unreliable (14).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Previous studies reported advanced bone age maturation in children with premature pubarche due to NCCAH.

    “This is in contrast with previous studies reporting advanced BA maturation in children with PP due to NCCAH (20,21).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [20] source

      Not checked in the free run.

    • cites [21] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Approximately 65-75% of CAH patients are compound heterozygotes, and clinical expression correlates with the less severely mutated allele and residual 21-hydroxylase activity.

    “Approximately 65-75% of the CAH patients are compound heterozygotes, and the clinical expression correlates with the less severely mutated allele, and, consequently, with the residual activity of 21-OH (14).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The I172N and large deletion combination was previously described as responsible for severe salt-wasting disease.

    “The other patient was a compound heterozygote for I172N and a large deletion, a combination previously described as responsible for severe salt-wasting disease (32).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32]

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The different percentages of severe and mild CYP21A2 mutations in PP children compared to adult NCCAH patients may indicate that the enzyme defect is under-diagnosed in childhood and may not lead to hyperandrogenic symptoms in adulthood.

    “The different percentages of severe and mild CYP21A2 gene mutations found in PP children compared to adult patients with NCCAH may indicate that the enzyme defect is under-diagnosed in childhood and may not lead to the development of hyperandrogenic symptoms in adulthood.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The I172N mutation is usually associated with the classic simple virilizing form of the disease.

    “The first child was homozygous for the I172N mutation, which is usually associated with the classic simple virilizing form of the disease.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [31] source

      Not checked in the free run.

    • cites [26] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In a French cohort of children with premature pubarche, the threshold of 2 ng/ml corresponded to the 94th percentile of the hormone level distribution.

    “Similar figures were recently described in a French cohort of children with PP in whom the threshold level of 2 ng/ml (6 nmol/l) corresponded to the 94th percentile of the distribution of the hormone levels in the group of patients studied (22).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The ACTH-stimulated 17-OHP cutoff of 10 ng/ml (30 nmol/l) is currently used for NCCAH diagnosis, though cutoffs of 20 and 30 ng/ml have been proposed.

    “The cutoff level for ACTH-stimulated 17-OHP of 10 ng/ml (30 nmol/l) has been currently used for the diagnosis of NCCAH, although it has been the subject of discussion in the literature, with cutoffs of 20 (60 nmol/l) and even 30 ng/ml (90 nmol/l) being instead proposed by some authors (23)(24)(25).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites (23)(24)(25)

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The phenotype-genotype correspondence is not strict, and phenotype can be milder than expected.

    “The failure of strict correspondence of phenotype and genotype with the possibility of the former to be even milder than expected”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The genotype classification (mild/mild, mild/severe, severe/severe) reflects the actual enzymatic severity.
    • Rests on an assumption: The diagnosis of NCCAH by genotype is the gold standard.

  • May combine two claims.

    Interpretationcitation

    The 52.7% homozygosity for mild mutations is higher than in French adult and Brazilian adult series but similar to pediatric Spanish and Jewish series.

    “a percentage strikingly higher than that recently reported in a large series of French adult patients (26) and in previous studies in adult Brazilian patients (23), but similar to the one detected in pediatric Spanish (29) and Jewish patients (30), mostly comprised of children with PP.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [26] source

      Not checked in the free run.

    • cites [23] source

      Not checked in the free run.

    • cites [29] source

      Not checked in the free run.

    • Rests on an assumption: The prior studies' cohorts are comparable to this cohort for comparing mutation frequencies.

  • May combine two claims.

    Interpretationown data

    A distinct phenotype such as PP can result from different molecular genetic defects and variable hormone levels, suggesting modifier factors may modulate disease expression.

    “In conclusion, the results of this study indicate that a distinct phenotype such as PP can be the result of different molecular genetic defects and variable hormone levels, suggesting that modifier factors may modulate the expression of the disease.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Decreased methylation of the androgen receptor gene in hair follicles was shown to produce increased gene expression, more active androgen receptors, and increased sensitivity to androgens in children with IPP.

    “In the latter, a decreased methylation of the androgen receptor gene in an androgen target tissue such as hair follicles was shown to produce an increased gene expression, and in turn, more active androgen receptors and increased sensitivity to androgens.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    A plausible reason for the discrepant results is that pediatric patients with PP and 21-OH deficiency are under-diagnosed in childhood and do not develop signs requiring testing in adulthood.

    “A plausible reason for the discrepant results might be that pediatric patients with PP and 21-OH deficiency may be under-diagnosed in childhood and do not develop signs of the disease requiring hormonal and genetic testing, in adulthood.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The phenotype cannot always be predicted from the genotype, and the severe mutation allele has a minor influence on biological and clinical expression.

    “This indicates that the phenotype cannot be always predicted from the genotype and suggests a minor influence of the allele carrying the severe mutation on both the biological and the clinical expression of the disease”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The genotype classification (mild/mild, mild/severe, severe/severe) reflects the actual enzymatic severity.
    • Rests on an assumption: The diagnosis of NCCAH by genotype is the gold standard.
36 of 36

  • The paper relies on this without support.

    The mutation distribution in adult NCCAH patients is known and comparable enough to the pediatric premature pubarche population to support inferences about under-diagnosis in childhood.

    “The different percentages of severe and mild CYP21A2 gene mutations found in PP children compared with adult NCCAH patients is an indirect evidence that the enzyme defect is under-diagnosed in childhood”

  • The paper relies on this without support.

    A suboptimal cortisol response to ACTH stimulation in NCCAH patients indicates a risk of clinically significant adrenal insufficiency that warrants consideration of stress-dose glucocorticoids.

    “Stress-dose glucocorticoids should be considered in patients with suboptimal cortisol response to ACTH stimulation.”

  • The paper relies on this without support.

    The 55 children with PP and CYP21A2 mutations on both alleles are representative of all children with PP and NCCAH.

    “In children with PP, non-classic 21-OH deficiency can be ruled out only by means of ACTH testing.”

  • The paper relies on this without support.

    The genotype classification (mild/mild, mild/severe, severe/severe) reflects the actual enzymatic severity.

    “The comparison of the clinical and hormonal phenotype of the different genotypes revealed no differences between the mild/mild and mild/severe genotypes”

  • The paper relies on this without support.

    The unaffected children in the cohort do not have NCCAH.

    “corresponding to the 80th percentile for the unaffected children”

  • The paper relies on this without support.

    The prior studies' cohorts are comparable to this cohort for comparing mutation frequencies.

    “a percentage strikingly higher than that recently reported in a large series of French adult patients (26) and in previous studies in adult Brazilian patients (23), but similar to the one detected in pediatric Spanish (29) and Jewish patients (30)”

  • The paper relies on this without support.

    The diagnosis of NCCAH by genotype is the gold standard.

    “The concordance between the baseline and ACTH-stimulated 17-OHP values showing the best sensitivity for the diagnosis of NCCAH (baseline 0.89 ng/ml (2.7 nmol/l), kappa index: 0.33; ACTHstimulated 10 ng/ml (30 nmol/l), kappa index: 0.71) and genotype is also shown.”
7 of 7

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Baseline 17-OHP genotype comparison changes between results and discussion

    Major

    The results report no baseline 17-OHP difference between mild/mild and mild/severe patients, but the discussion reports a significant difference between those genotypes.

  • The 14 ng/ml cutoff cannot have both 100% specificity and false positives

    Major

    The reported two false positives for the stimulated ROC cutoff contradict its stated 100% specificity.

  • Baseline cutoff performance conflicts with the reported classification counts

    Major

    At the 2.82 ng/ml cutoff, six missed patients among 55 imply 89.1% sensitivity, not 84.1%. Six false positives among the 97 non-NCCAH children imply 93.8% specificity, not 94.9%.

  • IPP percentage does not match the group size

    Minor

    Eight of the 47 IPP children is 17.0%, not 16%.

    Reported 16 · recomputed 17.021277

  • Abstract overstates the proportion with two mild mutations

    Minor

    The abstract reports 54.5%, whereas the results and Table 1 report 52.7% (29 of 55 patients).

  • Direction of the post-ACTH cortisol difference reverses

    Minor

    One results statement says NCCAH patients had significantly lower post-ACTH cortisol than the other groups; a later statement says it was significantly higher.

6 of 6

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Authors
Ghizzoni, L., Cappa, M., Vottero, A., Ubertini, G., Carta, D., Di Iorgi, N., Gasco, V., Marchesi, M., Raggi, V., Ibba, A., Napoli, F., Massimi, A., Maghnie, M., Loche, S., & Porzio, O.
Affiliations
  • University of Turin (IT)
  • Bambino Gesù Children's Hospital (IT)
  • University of Parma (IT)
  • Ospedale Microcitemico (IT)
  • Istituto Giannina Gaslini (IT)
  • University of Rome Tor Vergata (IT)
Corresponding author
Ghizzoni, Lucia
ORCID
Venue
European Journal of Endocrinology
Publisher
Oxford University Press (OUP)
Published
2011-08
Volume
165
Issue
2
Pages
307-314
ISSN
  • 0804-4643 (ISSN-L)
  • 1479-683X
DOI
10.1530/eje-11-0119
OpenAlex
W2142523386
Semantic Scholar
965b01b3461e560397463c99e1bb01b8628ce6c0
Cited by
41
References
36
Citations by year
2026: 1 · 2025: 2 · 2024: 2 · 2023: 1 · 2022: 2 · 2021: 5 · 2020: 2 · 2019: 4 · 2018: 3 · 2017: 2 · 2016: 3 · 2015: 2 · 2014: 5 · 2013: 3 · 2012: 4
FWCI
1.56
Type
journal article
Language
en
Open access
Licence
other-oa
Locations
  • European Journal of Endocrinology (publishedVersion)
  • PubMed (publishedVersion)
  • Cineca Institutional Research Information System (Tor Vergata University) (submittedVersion, other-oa)
  • CINECA IRIS Institutial Research Information System (University of Genoa) (submittedVersion)
  • Institutional Research Information System University of Turin (University of Turin) (submittedVersion)
Topics
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Sexual Differentiation and Disorders
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Clinical Biochemistry › Metabolism and Genetic Disorders
Keywords
premature pubarche, non-classical congenital adrenal hyperplasia, 21-hydroxylase deficiency, 17-hydroxyprogesterone, ACTH stimulation test, cortisol, CYP21A2 mutations, compound heterozygosity, children, diagnostic thresholds, underdiagnosis
MeSH terms
Adrenal Hyperplasia, Congenital, Adult, Child, Child, Preschool, DNA Mutational Analysis, Female, Genotype, Humans, Hydrocortisone, Infant, Italy, Male, Puberty, Precocious, Retrospective Studies, Steroid 21-Hydroxylase, Cohort Studies, 17-alpha-Hydroxyprogesterone, Polymorphism, Single Nucleotide

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.

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