Molecular CYP21A2 diagnosis in 480 Brazilian patients with congenital adrenal hyperplasia before newborn screening introduction
Abstract
Background: Most congenital adrenal hyperplasia (CAH) patients carry CYP21A2 mutations derived from conversion events involving the pseudogene, and the remaining carry new mutations. Objective: To review causal mutations and genotype–phenotype correlation in 480 Brazilian patients. Methods: DNA was extracted from 158 salt-wasters (SWs), 116 simple virilizing (SV), and 206 nonclassical (NC) patients. Fourteen point mutations were screened by allele-specific PCR, large rearrangements by Southern blotting/MLPA, and sequencing was performed in those with incomplete genotype. The gene founder effect was analyzed by microsatellite studies. Patients were divided into six genotypes (Null; A: <2%; B: 3–7%; C: >20% of residual enzymatic activity (EA); D: unknown EA; E: incomplete genotype). Results: Targeted methodologies defined genotype in 87.6% of classical and in 80% of NC patients and the addition of sequencing in 100 and 83.5%, respectively. The most frequent mutations were p.V281L (26.6% of alleles), IVS2-13A/C>G (21.1%), and p.I172N (7.5%); seven rare mutations and one novel mutation (p.E351V) were identified. Gene founder effect was observed in all but one (p.W19X) mutation. Null, A, B, and C genotypes correlated with SW (88%), SW (70%), SV (98%), and NC forms (100%), respectively. In group D, the p.E351V mutation correlated with classical form and group E comprised exclusively NC-patients. ACTH-stimulated 17OHP level of 44.3ng/mL was the best cutoff to identify NC-patients carrying severe mutations. Conclusions: We identified a good genotype–phenotype correlation in CAH, providing useful data regarding prediction of disease’s severity; moreover, we suggest that ACTH-stimulated 17OHP levels could predict carrier status for severe mutations. Sequencing is essential to optimize molecular diagnosis in Brazilian CAH patients.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In a large Brazilian cohort, nine novel or rare variants were identified, several of which exhibited clear founder effects and shared haplotypes with Spanish and Portuguese patients.
“In a large Brazilian cohort, nine novel or rare variants were identified, several of which (p.(Arg408Cys), c.1450_1451insC, p.(His365Tyr), c.293-2C>G, p.(Gly424Ser) exhibited clear founder effects and shared haplotypes with Spanish and Portuguese patients, reflecting the historical Iberian contribution to Brazilian ancestry (22, 27, 40, 41).”
From Evolution of molecular diagnostic strategies for 21-hydroxylase deficiency: from classical methods to advanced genomic techniques (2026) · cites this paper as [22]
A strong correlation between genotype and phenotype has been consistently reported across multiple populations in 21-OHD.
“In 21-OHD, a strong correlation between genotype and phenotype has been consistently reported across multiple populations (22, 26, 46, 47).”
From Evolution of molecular diagnostic strategies for 21-hydroxylase deficiency: from classical methods to advanced genomic techniques (2026) · cites this paper as [22]
Population-based studies reveal rare or population-specific alleles, highlighting extensive allelic heterogeneity of 21-OHD and the necessity of using ethnically tailored genetic panels for accurate diagnosis and effective genetic counseling.
“Nevertheless, population-based studies continue to reveal rare or population-specific alleles, highlighting the extensive allelic heterogeneity of 21-OHD and the necessity of using ethnically tailored genetic panels for accurate diagnosis and effective genetic counseling (5, 16, 19, 22, 28, 33–35).”
From Evolution of molecular diagnostic strategies for 21-hydroxylase deficiency: from classical methods to advanced genomic techniques (2026) · cites this paper as [22]
The salt-wasting form generally results from combinations of two severe alleles (groups 0 or A); the simple-virilizing form arises in patients homozygous for group B variants or compound heterozygous for group B with null/A; the nonclassical phenotype usually manifests in carriers of two mild alleles (group C) or combinations of mild and severe variants.
“Consequently, the SW form generally results from combinations of two severe alleles (groups 0 or A), whereas the SV form arises in patients homozygous for group B variants, or compound heterozygous of group B variants with groups null or A. The NC phenotype usually manifests in carriers of two mild alleles (group C) or combinations of mild and severe (groups null, A or B) variants (22, 26, 47, 48)”
From Evolution of molecular diagnostic strategies for 21-hydroxylase deficiency: from classical methods to advanced genomic techniques (2026) · cites this paper as [22]
Only 5-10% of small pathogenic variants in CYP21A2 occur independently of gene conversion events, and some of these have founder effects.
“In contrast, only 5-10% of small pathogenic variants in CYP21A2 occur independently of gene conversion events; some of these have founder effects, providing valuable insights into population history and migration patterns (5, 16, 19–22).”
From Evolution of molecular diagnostic strategies for 21-hydroxylase deficiency: from classical methods to advanced genomic techniques (2026) · cites this paper as [22]
Most affected individuals are compound heterozygotes, and clinical outcome is typically determined by the allele that maintains the highest residual enzyme activity.
“Most affected individuals are compound heterozygotes, and the clinical outcome is typically determined by the allele that maintains the highest residual enzyme activity.”
From Evolution of molecular diagnostic strategies for 21-hydroxylase deficiency: from classical methods to advanced genomic techniques (2026) · cites this paper as [22]
Sanger sequencing has been regarded as the gold standard for CYP21A2 analysis and remains the reference method in diagnostic and research laboratories worldwide.
“For more than three decades, Sanger sequencing has been regarded as the gold standard for CYP21A2 analysis and remains the reference method in diagnostic and research laboratories worldwide (22, 47, 53).”
From Evolution of molecular diagnostic strategies for 21-hydroxylase deficiency: from classical methods to advanced genomic techniques (2026) · cites this paper as [22]
Cites
Krone, N., Braun, A., Roscher, A. A., Knorr, D., & Schwarz, H. P. (2000) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jcem.85.3.6441 · Cited by 397 · see citing works
New, M. I., Abraham, M., Gonzalez, B., Dumic, M., Razzaghy-Azar, M., Chitayat, D., Sun, L., Zaidi, M., Wilson, R. C., & Yuen, T. (2013) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.1300057110 · Cited by 365 · see citing works
Nonclassical 21-Hydroxylase Deficiency
New, M. I. (2006) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2006-1645 · Cited by 315 · see citing works
Higashi, Y., Hiromasa, T., Tanae, A., Miki, T., Nakura, J., Kondo, T., Ohura, T., Ogawa, E., Nakayama, K., & Fujii-Kuriyama, Y. (1991) · The Journal of Biochemistry · doi:10.1093/oxfordjournals.jbchem.a123433 · Cited by 201 · see citing works
Finkielstain, G. P., Chen, W., Mehta, S. P., Fujimura, F. K., Hanna, R. M., Van Ryzin, C., McDonnell, N. B., & Merke, D. P. (2011) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2010-0319 · Cited by 192 · see citing works
Wedell, A., & Luthman, H. (1993) · Human Molecular Genetics · doi:10.1093/hmg/2.5.499 · Cited by 160 · see citing works
Krone, N., Rose, I. T., Willis, D. S., Hodson, J., Wild, S. H., Doherty, E. J., Hahner, S., Parajes, S., Stimson, R. H., Han, T. S., et al. (2013) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2012-3343 · Cited by 119 · see citing works
Marino, R., Ramirez, P., Galeano, J., Perez Garrido, N., Rocco, C., Ciaccio, M., Warman, D. M., Guercio, G., Chaler, E., Maceiras, M., et al. (2011) · Clinical Endocrinology · doi:10.1111/j.1365-2265.2011.04123.x · Cited by 98 · see citing works
Extraadrenal 21-Hydroxylation by CYP2C19 and CYP3A4: Effect on 21-Hydroxylase Deficiency
Gomes, L. G., Huang, N., Agrawal, V., Mendonça, B. B., Bachega, T. A. S. S., & Miller, W. L. (2009) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2008-1174 · Cited by 91 · see citing works
Self-citationSpeiser, P. W., Knochenhauer, E. S., Dewailly, D., Fruzzetti, F., Marcondes, J. A. M., & Azziz, R. (2000) · Molecular Genetics and Metabolism · doi:10.1006/mgme.2000.3036 · Cited by 89 · see citing works
Self-citationBaumgartner-Parzer, S. M., Schulze, E., Waldhäusl, W., Pauschenwein, S., Rondot, S., Nowotny, P., Meyer, K., Frisch, H., Waldhauser, F., & Vierhapper, H. (2001) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jcem.86.10.7898 · Cited by 74 · see citing works
Tardy, V., Menassa, R., Sulmont, V., Lienhardt-Roussie, A., Lecointre, C., Brauner, R., David, M., & Morel, Y. (2010) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2009-1202 · Cited by 73 · see citing works
Araújo, R. S., Mendonca, B. B., Barbosa, A. S., Lin, C. J., Marcondes, J. A. M., Billerbeck, A. E. C., & Bachega, T. A. S. S. (2007) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2006-2163 · Cited by 70 · see citing works
Self-citationEzquieta, B., Cueva, E., Varela, J., Oliver, A., Fernández, J., & Jariego, C. (2002) · Acta Paediatrica · doi:10.1080/080352502760148595 · Cited by 47 · see citing works
Araujo, R. S., Billerbeck, A. E. C., Madureira, G., Mendonca, B. B., & Bachega, T. A. S. S. (2005) · Clinical Endocrinology · doi:10.1111/j.1365-2265.2005.02184.x · Cited by 42 · see citing works
Self-citationFardella, C. E., Poggi, H., Pineda, P., Soto, J., Torrealba, I., Cattani, A., Oestreicher, E., & Foradori, A. (1998) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jcem.83.9.5071 · Cited by 35 · see citing works
Santomé Collazo, J. L., Cirujano Segura, A., Ferreiro Fernández, B., Casado Fúnez, C., Muñoz-Pacheco, R., & Ezquieta Zubicaray, B. (2010) · Medicina Clínica · doi:10.1016/j.medcli.2009.11.039 · Cited by 10 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Genetics of congenital adrenal hyperplasia
Krone, N., & Arlt, W. (2009) · Best Practice & Research Clinical Endocrinology & Metabolism · doi:10.1016/j.beem.2008.10.014 · Cited by 312 · see citing works
Baumgartner-Parzer, S., Witsch-Baumgartner, M., & Hoeppner, W. (2020) · European Journal of Human Genetics · doi:10.1038/s41431-020-0653-5 · Cited by 110 · see citing works
The Complexities in Genotyping of Congenital Adrenal Hyperplasia: 21-Hydroxylase Deficiency
Pignatelli, D., Carvalho, B. L., Palmeiro, A., Barros, A., Guerreiro, S. G., & Macut, D. (2019) · Frontiers in Endocrinology · doi:10.3389/fendo.2019.00432 · Cited by 95 · see citing works
Riedl, S., Röhl, F.-W., Bonfig, W., Brämswig, J., Richter-Unruh, A., Fricke-Otto, S., Bettendorf, M., Riepe, F., Kriegshäuser, G., Schönau, E., et al. (2019) · Endocrine Connections · doi:10.1530/ec-18-0281 · Cited by 69 · see citing works
Molecular diagnosis of steroid 21-hydroxylase deficiency: A practical approach
Arriba, M., & Ezquieta, B. (2022) · Frontiers in Endocrinology · doi:10.3389/fendo.2022.834549 · Cited by 30 · see citing works
Turan, I., Tastan, M., Boga, D. D., Gurbuz, F., Kotan, L. D., Tuli, A., & Yüksel, B. (2020) · European Journal of Medical Genetics · doi:10.1016/j.ejmg.2019.103782 · Cited by 25 · see citing works
Kocova, M., Anastasovska, V., & Falhammar, H. (2020) · Endocrine · doi:10.1007/s12020-020-02323-3 · Cited by 24 · see citing works
Kopacek, C., Prado, M. J., da Silva, C. M. D., de Castro, S. M., Beltrão, L. A., Vargas, P. R., Grandi, T., Rossetti, M. L. R., & Spritzer, P. M. (2019) · Jornal de Pediatria · doi:10.1016/j.jped.2018.03.003 · Cited by 17 · see citing works
Characteristics of In2G Variant in Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency
Kocova, M., Concolino, P., & Falhammar, H. (2022) · Frontiers in Endocrinology · doi:10.3389/fendo.2021.788812 · Cited by 15 · see citing works
Weber, J., Tanawattanacharoen, V. K., Seagroves, A., Liang, M. C., Koppin, C. M., Ross, H. M., Bachega, T. A. S. S., Geffner, M. E., Serrano-Gonzalez, M., Bhullar, G., et al. (2022) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgab600 · Cited by 11 · see citing works
Self-citationMiranda, M. C. D., Oliveira, A. C. M. D., Soares, G. J., Batatinha, J. A. P., Latronico, A. C., Mendonca, B. B., & Bachega, T. A. S. S. (2026) · Frontiers in Endocrinology · doi:10.3389/fendo.2026.1770274 · Cited by 2 · see citing works
“By resolving ambiguous biochemical results and distinguishing transient hyper-17-OHP from true disease, genotyping reduces false positives rates, unnecessary hospitalization, and parental anxiety (1, 16, 22, 81).”
InfluentialSelf-citation
- Authors
- de Carvalho, D. F., Miranda, M. C., Gomes, L. G., Madureira, G., Marcondes, J. A. M., Billerbeck, A. E. C., Rodrigues, A. S., Presti, P. F., Kuperman, H., Damiani, D., Mendonca, B. B., & Bachega, T. A. S. S.
- Affiliations
- 1Laboratório de Hormônios e Genética Molecular- LIM/42Unidade de Adrenal, Disc. de Endocrinologia e Metabologia
- 2Unidade de Endocrinologia PediátricaInstituto da Criança, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Universidade de São Paulo (BR)
- Venue
- European Journal of Endocrinology
- Publisher
- Oxford University Press (OUP)
- Published
- 2016-08
- Volume
- 175
- Issue
- 2
- Pages
- 107-116
- ISSN
- 0804-4643 (ISSN-L)
- 1479-683X
- OpenAlex
- W2408379723
- Cited by
- 75
- References
- 17
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 4 · 2023: 6 · 2022: 9 · 2021: 18 · 2020: 8 · 2019: 10 · 2018: 5 · 2017: 8
- FWCI
- 3.99
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Journal of Endocrinology (publishedVersion)
- PubMed (publishedVersion)
- 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
- congenital adrenal hyperplasia, CYP21A2 mutations, genotype-phenotype correlation, salt-wasting CAH, simple virilizing CAH, founder effect, novel mutations, Brazilian patients
- MeSH terms
- Adolescent, Adrenal Hyperplasia, Congenital, Alleles, Brazil, Child, Child, Preschool, Female, Genotype, Humans, Infant, Infant, Newborn, Male, Phenotype, Steroid 21-Hydroxylase, Point Mutation, Molecular Diagnostic Techniques, Genetic Association Studies
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.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
