Congenital adrenal hyperplasia

Last revised by Albert P. Matifoll on 27 Oct 2022

Congenital adrenal hyperplasia, previously known as adrenogenital syndrome, is a group of seven autosomal recessive disorders relating to an enzyme deficiency affecting adrenal steroidogenesis.

The incidence is highly variable depending on the enzyme deficiency ranging from 1 in 200-1000 for non-classic 21-alpha-hydroxylase deficiency, 1 in 10,000-20,000 for classic 21-alpha-hydroxylase deficiency through to very rare (<30 cases reported of P450 cholesterol side-chain cleavage enzyme deficiency) 8.

There are a variety of phenotypes depending on the production or lack thereof of glucocorticoid, mineralocorticoid and/or sex steroids. Common clinical presentations include 8:

  • virilization / atypical genitalia in females (due to androgen excess)

  • precocious puberty, hirsutism, oligomenorrhea/amenorrhea, female infertility

  • electrolyte imbalance related to a salt-losing crisis (neonatal salt wasting)

  • testicular masses

  • hypotension

Neonatal screening for 21-alpha-hydroxylase deficiency is present in many countries 8.

Congenital adrenal hyperplasia is a group of seven autosomal recessive disorders of congenital cortisol synthesis involving a deficiency of one of the following enzymes 8:

  • 21-alpha-hydroxylase

    • ~90-95% of cases 5,8

    • mutation in the CYP21A2 gene 10

  • 11-beta-hydroxylase

  • 17-alpha-hydroxylase

  • 3-beta-hydroxysteroid dehydrogenase type 2

  • steroidogenic acute regulatory protein

  • P450 cholesterol side-chain cleavage enzyme

  • P450 oxidoreductase

The adrenal glands are most commonly affected, followed by the gonads 9.

20-30% of patients with congenital adrenal hyperplasia have adrenal tumors 10:

Features of adrenal hyperplasia may be present 9 and the presence of any adrenal tumor should be sought 10.

Testicular masses may be identified representing testicular adrenal rest tumors (most but not all males 9).

Enlarged loops of adrenal gland or "cerebriform pattern" is highly specific 3.

Management relies on replacing the deficient glucocorticoid, mineralocorticoid, and/or sex steroid as well as anti-hypertensive treatment 8.

  • normal neonatal adrenal: can be differentiated from congenital adrenal hyperplasia (CAH) by the characteristic cerebriform appearance on sonography in CAH

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Cases and figures

  • Case 1
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  • Case 2: with female pseudohermaphroditism
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  • Case 3: testicular adrenal rests
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  • Case 4: with multiple tumors
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  • Case 5
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