Elevated Urine Pregnanetriolone Definitively Establishes the Diagnosis of Classical 21-Hydroxylase Deficiency in Term and Preterm Neonates

Abstract

Elevated blood 17alpha-hydroxyprogesterone (17OHP) level, although widely used for the screening of classical 21-hydroxylase deficiency (21OHD) in neonates, has frequently been found in some neonates without classical 21OHD, particularly preterm neonates. We studied the diagnostic value of the metabolite of 21-deoxycortisol (pregnanetriolone, Ptl) and the metabolite of 17OHP (pregnanetriol, PT) in identifying 21OHD in term and preterm neonates with elevated blood 17OHP on the newborn screening. Spot urine samples from 59 classical 21OHD neonates (50 term, 9 preterm), 83 neonates without 21OHD having transiently elevated blood 17OHP (non-21OHD) (49 term, 34 preterm), and 62 control term neonates were studied using gas chromatography/mass spectrometry in selected ion monitoring analysis for Ptl, PT, 5beta-tetrahydrocortisone (betaTHE), and 5alpha-tetrahydrocortisone (alphaTHE). Ptl and Ptl/(betaTHE+alphaTHE) showed no overlap between 21OHD and non-21OHD, and 21OHD and controls, respectively (Ptl was 0.46-124 mg/g creatinine in 21OHD term, 0.80-26.9 mg/g creatinine in 21OHD preterm, < or = 0.08 mg/g creatinine in non-21OHD term, < or =0.06 mg/g creatinine in non-21OHD preterm, and < or = 0.07 mg/g creatinine in controls). PT and PT/(betaTHE+alphaTHE) showed significant overlap between 21OHD and non-21OHD. The above data indicate that spot urine Ptl is a highly specific marker of 21OHD with a cutoff value of 0.1 mg/g creatinine, yielding an unambiguous separation between 21OHD and non-21OHD in term and preterm neonates.

Two-Step Biochemical Differential Diagnosis of Classic 21-Hydroxylase Deficiency and Cytochrome P450 Oxidoreductase Deficiency in Japanese Infants by GC-MS Measurement of Urinary Pregnanetriolone/ Tetrahydroxycortisone Ratio and 11β-Hydroxyandrosterone

“…Second, by using a specific cutoff of 11HA, we were able to distinguish between C21OHD and PORD. Although a distinctive steroid excretion pattern in C21OHD and PORD had been reported (3,5,6 ), no clear cutoff of urinary steroid metabolites was reported in any ages to discriminate between C21OHD and PORD. To the best of our knowledge, this is the first report of a cutoff for biochemical differential diagnosis of C21OHD and PORD in infants.…”

“…We measured Ptl and the cortisol metabolites 5␣-tetrahydrocortisone and 5␤-tetrahydrocortisone (sum of these metabolites termed THEs) and calculated the ratio of Ptl to the cortisol metabolites (Ptl/THEs) (5,9 ) to differentiate C21OHD and PORD from TH17OHP and controls. Ptl was considered to be equal to 0.001 mg/g creatinine for calculation in infants whose Ptl was under the detection limit (Ͻ0.001 mg/g creatinine).…”

“…In addition to increased concentrations of 17OHP, clinical manifestations of C21OHD and PORD can be similar, leading to difficulty in differential diagnosis (3,4 ). We previously reported the biochemical differential diagnosis of C21OHD from transient hyper 17OHPnemia (TH17OHP) and controls in term and preterm neonates by measuring urinary pregnanetriolone (Ptl), which was a final metabolite of 21-deoxycortisol (21DOF) (5 ). Shackleton et al (6 ) reported biochemical differential diagnosis of PORD from controls by a distinctive steroid excretion pattern, namely low urinary metabolites of cortisol and androgens and high metabolites of pregnenolone and progesterone.…”

LC/MS/MS of Steroids Having Vicinal Diol as Electrospray-Active Boronates

“…15) However, this approach has several limitations; enzymatic hydrolysis is time-consuming and the recovery of PT is sometimes not quantitative due to incomplete hydrolysis. Here, in a pilot study, we attempted to detect the trace unconjugated PT excreted in the urine of healthy subjects using the DAPBderivatization followed by LC/MS/MS.…”

Genetic Analysis of Two Japanese Patients with Non-classical 21-Hydroxylase Deficiency

“…Urine pregnanetriolone (Ptl) was measured using spot urine samples with gas chromatography/mass spectrometry in selected ion monitoring analysis as described previously (13,14). (17).…”