Our recruitment of patients continues to be excellent and represents the largest cohort of CAH and FMPP patients ever seen at one center. To date, we have enrolled 301 patients with CAH, and 15 patients with FMPP. Comprehensive clinical phenotyping of patients with CAH due to 21-hydroxylase deficiency has been performed. Detailed clinical evaluations reveal great variation in treatment approaches of referred patients, especially amongst adults, with only 30% of patients in acceptable disease control based on adrenal hormones. Adult short stature, abnormal growth and development of children, cardiovascular risk factors, reduced bone mineral density and adrenal and testicular tumor formation are common. Further studies exploring these adverse outcomes are underway. Patients with CAH and other forms of adrenal insufficiency have been reported to have poor quality-of-life. Cognition, emotional processing, memory and quality-of-life is being evaluated. Genotyping and genetic counseling are important in the management of CAH, and genotyping has been suggested as a potential second tier screen to hormonal measurements in neonatal screening programs. The gene encoding 21-hydroxylase, CYP21A2, is mapped to the short arm of chromosome 6 (6p21.3) within the HLA complex. The high rate of genetic variability at this locus, the presence of CYP21A2 gene duplications, and the presence of the CYP21A1P pseudogene complicate the determination of disease and carrier status. In our large cohort of patients with CAH due to 21-hydroxylase deficiency, we reported that the widely used PCR-based CYP21A2 analysis that targets most common mutations failed to identify mutations in 10 percent of our patients, more often than expected. We also found that unusual duplicated CYP21A2 haplotypes sometimes interferes with genotyping and may result in erroneous results reported by commercial laboratories. In addition, we recently found that junction site analysis of large gene deletions is clinically relevant and can explain why some patients with large deletions have a mild phenotype. Our findings to date have broad implications in the use of genetic analysis in the diagnosis and management of CAH. We are currently comparing various methodologies and aim to establish a suggested protocol for performing CYP21A2 genetic analysis and incorporating genetic analysis into the management of CAH. An important concurrent project is the evaluation of neighboring genes in relation to phenotype. In collaboration with scientists from NIA, we are evaluating a novel CAH-Tenascin X Contiguous Gene Deletion Syndrome, we termed CAH-X Syndrome. Tenascin-X deficiency, in recessive or dominant form, has been proposed as a cause of hypermobility type Ehlers-Danlos Syndrome (EDS). In the first ever systematic study tenascin deficiency in CAH patients, we found that 14 (7 percent) of 193 consecutive unrelated CAH patients have the novel CAH-X Syndrome. Further studies are underway to better define the clinical, molecular and biochemical aspects of this novel CAH-X syndrome.

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Dagalakis, Urania; Mallappa, Ashwini; Elman, Meredith et al. (2016) Positive fertility outcomes in a female with classic congenital adrenal hyperplasia following bilateral adrenalectomy. Int J Pediatr Endocrinol 2016:10
Chen, Wuyan; Perritt, Ashley F; Morissette, Rachel et al. (2016) Ehlers-Danlos Syndrome Caused by Biallelic TNXB Variants in Patients with Congenital Adrenal Hyperplasia. Hum Mutat 37:893-7
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Morissette, Rachel; Chen, Wuyan; Perritt, Ashley F et al. (2015) Broadening the Spectrum of Ehlers Danlos Syndrome in Patients With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 100:E1143-52
Stolze, Brian R; Gounden, Verena; Gu, Jianghong et al. (2015) Use of micro-HPLC-MS/MS method to assess diurnal effects on steroid hormones. Clin Chem 61:556-8
DiSandro, M; Merke, D P; Rink, R C (2015) Review of current surgical techniques and medical management considerations in the treatment of pediatric patients with disorders of sex development. Horm Metab Res 47:321-8
Morissette, Rachel; Merke, Deborah P; McDonnell, Nazli B (2014) Transforming growth factor-β (TGF-β) pathway abnormalities in tenascin-X deficiency associated with CAH-X syndrome. Eur J Med Genet 57:95-102
Merke, Deborah P; Poppas, Dix P (2013) Management of adolescents with congenital adrenal hyperplasia. Lancet Diabetes Endocrinol 1:341-52
Xu, Zhi; Chen, Wuyan; Merke, Deborah P et al. (2013) Comprehensive mutation analysis of the CYP21A2 gene: an efficient multistep approach to the molecular diagnosis of congenital adrenal hyperplasia. J Mol Diagn 15:745-53
Mueller, Sven C; Daniele, Teresa; MacIntyre, Jessica et al. (2013) Incentive processing in Congenital Adrenal Hyperplasia (CAH): a reward-based antisaccade study. Psychoneuroendocrinology 38:716-21

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