Leydig cell tumors are the most common type of testicular sex cord stromal tumors. The presence of the Y chromosome is associated with tumor risk in sex development disorders (DSD), however tumor development without Y chromosome is extremely rare. A 16-year-old boy diagnosed with Leydig cell tumor due to a mass in the right testis was referred after the right orchiectomy. On physical examination, the left testis was 10 mL, and there was a labial residue in penoscrotal region. Bilateral gynecomastia was present. The karyotype was 46,XX and SRY was double-positive on fluorescent in situ hybridization analysis. Ifosfamide, carboplatin and etoposide chemotherapy was initiated due to the Leydig cell tumor. Here, we report the first pediatric case having 46,XX testicular DSD with double-positive SRY and a Leydig cell tumor.

Disorders of sex development (DSD) represent a group of congenital conditions in which there is a discrepancy between the chromosomal and (or) gonadal sex and the structure of the genitals. Within the DSD there is a subgroup of 46,XX testicular DSD (46,XX TDSD), which may be caused by the translocation of the SRY gene, and more rarely - due to other causes (SRY-negative forms). In this report, we present an observation of a patient with SRY-negative 46,XX TDSD, in whom the condition was initially regarded as a virile form of congenital adrenal hyperplasia, then as idiopathic intrauterine virilization in a girl. Due to the development of virilization at the age of 11, the presence of testicular tissue was suspected. Molecular genetic analysis (whole exome sequencing with Sanger validation) revealed a de novo variant in exon 9 of the WT1 gene (chr11:32413528T>C), which, according to predictions, did not lead to a change in the amino acid sequence (p.Thr479=, NM_024426.6), but disrupted splicing, resulting in a previously described in 46,XX TDSD a change in the C-terminal domain of WT1. After verification of the diagnosis, a gonadectomy was performed and estrogen replacement therapy was prescribed. Thus, we have described a patient with a rare form of 46,XX TDSD caused by a variant in the WT1 gene. The presented observation illustrates the difficulties of differential diagnosis of intrauterine virilization syndrome in female karyotype. Термин нарушения формирования пола (НФП) объединяет группу врожденных состояний, при которых имеет место несоответствие между хромосомным и (или) гонадным полом и строением половых органов. К одной из групп НФП относятся тестикулярные нарушения при кариотипе 46,XX (ТНФП_46,XX), в структуре которой выделяют формы, обусловленные транслокацией гена SRY, и более редко — SRY-негативные формы. В настоящем сообщении нами представлено наблюдение пациента с SRY-негативным ТНФП_46,XX, у которого первоначально состояние расценивалось как вирильная форма врожденной дисфункции коры надпочечников (ВДКН), затем — как идиопатическая внутриутробная вирилизация у девочки. На фоне вирилизации в возрасте 11 лет было заподозрено наличие тестикулярной ткани. При молекулярно-генетическом обследовании (полноэкзомное секвенирование с валидацией методом С энгера) был обнаружен de novo вариант в экзоне 9 гена WT1 (chr11:32413528T>C), который по предсказаниям не приводил к изменению аминокислотной последовательности (p.Thr479=, NM_024426.6), однако нарушал сплайсинг, результатом чего было характерное для ТНФП_46,XX изменение C-концевого домена WT1. После верификации диагноза проведена гонадэктомия и назначена заместительная терапия эстрогенами. Таким образом, нами описан пациент с редкой формой ТНФП_46,XX, обусловленного вариантом в гене WT1. Представленное наблюдение иллюстрирует сложности дифференциальной диагностики синдрома внутриутробной вирилизации при женском кариотипе.

46,XX testicular disorder/difference of sex development (46,XX DSD) is a rare congenital condition, characterized by a combination of the typical female sex chromosome constitution, 46,XX, and a variable male phenotype. In the majority of individuals with 46,XX DSD, a Y chromosome segment containing the sex-determining region gene (SRY) has been translocated to the paternal X chromosome. However, the precise genomic content of the translocated segment and the genome-wide effects remain elusive. We performed long-read DNA sequencing, RNA sequencing and DNA methylation analyses on blood samples from 46,XX DSD (n = 11), male controls (46,XY; variable cohort sizes) and female controls (46,XX; variable cohort sizes), in addition to RNA sequencing and DNA methylation analysis on blood samples from males with Klinefelter syndrome (47,XXY, n = 22). We also performed clinical measurements on all 46,XX DSD and a subset of 46,XY (n = 10). We identified variation in the translocated Y chromosome segments, enabling subcategorization into 46,XX DSD (1) lacking Y chromosome material (n = 1), (2) with short Yp arms (breakpoint at 2.7-2.8 Mb, n = 2), (3) with medium Yp arms (breakpoint at 7.3 Mb, n = 1), and (4) with long Yp arms (n = 7), including deletions of AMELY, TBLY1 and in some cases PRKY. We also identified variable expression of the X-Y homologues PRKY and PRKX. The Y-chromosomal transcriptome and methylome reflected the Y chromosome segment lengths, while changes to autosomal and X-chromosomal regions indicated global effects. Furthermore, transcriptional changes tentatively correlated with phenotypic traits of 46,XX DSD, including reduced height, lean mass and testicular size. This study refines our understanding of the genetic composition in 46,XX DSD, describing the translocated Y chromosome segment in more detail than previously and linking variability herein to genome-wide changes in the transcriptome and methylome. Our sex chromosome constitution determines our sex, with the presence of a Y chromosome causing male sex determination (typically 46,XY) and the lack hereof resulting in female sex development (typically 46,XX). However, individuals can become male despite of them presenting with the classical female chromosome constitution. We term this “46,XX testicular disorder/difference of sex development” or “46,XX DSD” for short. Individuals with this condition are affected by a number of traits, such as infertility, short stature and altered hormone levels. We know that most cases of 46,XX DSD are caused by the sex-determining region of the Y chromosome being moved to one of the X chromosomes. However, we do not know the more precise size of the Y-chromosomal section or its effects on the genome. In this study we investigated 11 individuals with 46,XX DSD using novel and precise techniques than previously applied. Analyzing DNA, we found that their Y-chromosomal sections varied. This was reflected in multiple types of additional genetic analyses, investigating modifications to DNA and expression of genes. Our findings are the most accurate description of the Y-chromosomal section in 46,XX DSD to date, and indicate that the genomes of individuals with 46,XX DSD differ, with many potential mechanisms of action.

To investigate the genetic and clinical characteristics of 46, XX testicular disorders of sex development (DSD). We collected the clinical data on the patients with 46,XX testicular DSD diagnosed in the Center of Reproductive Medicine of the First Affiliated Hospital of Nanjing Medical University from January 2017 to January 2023, and analyzed their genetic and clinical characteristics and the SRY gene chromosomal location for those with SRY-positive. A total of 26 patients were included in this study, all with 46,XX and deletion of the AZFa, b and c regions, with a mean height of (168.3±5.9) cm, body weight of (64.0±7.5) kg, BMI of (22.66±2.79) kg/m2, left testis volume of (2.53±1.16) ml and right testis volume of (2.74±1.34) ml. The semen volume of the patients averaged 1.35 (0.18－2.78) ml, FSH (36.85±18.01) IU/L, LH (19.71±9.71) IU/L, and T (6.08±2.71) nmol/L. The SRY-negative patients had a higher incidence rate of development disorders in the reproductive system than the SRY-positive ones (5/6 vs 3/20, P = 0.004), but no statistically significant differences were observed in the other parameters. The SRY gene was localized at the end of Xp in 13 of the 14 SRY-positive cases, and at chromosome 15 in the other 1. 46,XX testicular DSD has some similarity and heterogeneity in genetics and clinical characteristics.

Substitution urethroplasty with either a flap or graft is the gold standard for treating long segment urethral strictures. In 1992, Burger and colleagues rediscovered and popularized buccal mucosal graft (BMG). After that El-Kassaby and colleagues, in 1993, used BMG to repair anterior urethral stricture. De la Chapelle syndrome or 46 XX male syndrome is a rare genetic disorder found in 1 in 20,000-25,000 men. This condition described as a presentation of male phenotype along a 46 xx karyotype. In this case report, we report a reconstructive surgery of a 46 XX male syndrome with ambiguous genitalia who presented with the chief complaint of bulbar urethral fistula opened in the perineal space. In this case, we used a buccal mucous graft with the ventral-onlay urethroplasty technique for reconstructing the failed bulbar urethra and closure of the fistula.