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Apparent Cortisone Reductase Deficiency: A Functional Defect in 11ß-Hydroxysteroid Dehydrogenase Type 1¹

Department of Medicine and Therapeutics (A.J.) and MRC Blood Pressure Group (R.F., P.C.W., J.M.C.C.), Western Infirmary, Glasgow G11 6NT; Department of Pathological Biochemistry (A.M.W.), Royal Infirmary, Glasgow G4 0SF; Department of Medical Sciences (B.R.W.), University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU, United Kingdom; and University of Texas Southwestern Medical Center (B.S.N., P.C.W.), Dallas, Texas 75235-9063

Address correspondence and requests for reprints to: Dr. Robert Fraser, MRC Blood Pressure Group, Western Infirmary, Glasgow G11 6NT, Scotland; E-mail: rfraser{at}clinmed.gla.ac.uk

A 36-yr-old woman was referred to the endocrine clinic for investigation of oligomenorrhea, hirsutism, and acne. She was plethoric and overweight with central fat distribution. Plasma cortisol was normal, but her adrenal glands were enlarged (CT scan). Urinary tetrahydrocortisone excretion rate was consistently high, raising the possibility of 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1) deficiency. In addition, 5ß- reduction of cortisol and cortisone was markedly enhanced. The levels of all cortisol metabolites were suppressed normally with dexamethasone, but conversion of oral cortisone acetate to plasma cortisol was delayed and subnormal compared with that of healthy volunteers. This was accompanied by a larger than normal increase in plasma cortisone concentration. Thus, the defect appears to be in 11ß-HSD1 activity and not in 5ß-reductase activity. Three close relatives of the subject showed no comparable abnormalities, and analysis of the coding region and exon/intron boundaries of the 11ß-HSD1 gene of the case revealed no differences from the consensus sequence. The defect may lie outside the coding region. Alternatively, some other inherited or acquired defect may lead to inhibition of this enzyme system.

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