Klinefelter's syndrome

Not to be confused with XYY syndrome.
Klinefelter's syndrome
Classification and external resources

47,XXY
ICD-10 Q98.0-Q98.4
ICD-9 758.7
eMedicine ped/1252
MeSH D007713

Klinefelter's syndrome, 47, XXY, or XXY syndrome is a condition in which males have an extra (an aneuploidy) X sex chromosome . While females have an XX chromosomal makeup, and males an XY, affected individuals have at least two X chromosomes and at least one Y chromosome.[1] Because of the extra chromosome, individuals with the condition are usually referred to as "XXY Males", or "47, XXY Males".[2]

Klinefelter's syndrome is the most common sex chromosome disorder[3] and the second most common condition caused by the presence of extra chromosomes. The condition exists in roughly 1 out of every 1,000 males. One in every 500 males has an extra X chromosome but does not have the syndrome.[4]

The principal effects are development of small testicles and reduced fertility. A variety of other physical and behavioral differences and problems are common, though severity varies and many boys and men with the condition have few detectable symptoms.

The syndrome was named after Dr. Harry Klinefelter, who in 1942 worked with Fuller Albright at Massachusetts General Hospital in Boston, Massachusetts and first described it in the same year.[5]

Contents

Signs and symptoms

Affected males are almost always effectively infertile, although advanced reproductive assistance is sometimes possible.[6] Some degree of language learning impairment may be present,[7] and neuropsychological testing often reveals deficits in executive functions.[8] In adults, possible characteristics vary widely and include little to no signs of affectedness, a lanky, youthful build and facial appearance, or a rounded body type with some degree of gynecomastia (increased breast tissue).[9] Gynecomastia is present to some extent in about a third of affected individuals, a slightly higher percentage than in the XY population, but only about 10% of XXY males' gynecomastia is noticeable enough to require surgery.[10]

The term hypogonadism in XXY symptoms is often misinterpreted to mean "small testicles" or "small penis". In fact, it means decreased testicular hormone/endocrine function. Because of this hypogonadism, individuals will often have a low serum testosterone level but high serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels.[11] Despite this misunderstanding of the term, however, it is true that XXY men also have microorchidism (i.e. small testicles).[11]

The more severe end of the spectrum of symptom expression is also associated with an increased risk of germ cell tumors, male breast cancer,[12] and osteoporosis,[4] risks shared to varying degrees[13] with females. Additionally, medical literature shows some individual case studies of Klinefelter's syndrome coexisting with other disorders, such as pulmonary disease, varicose veins, diabetes mellitus, and rheumatoid arthritis, but possible correlations between Klinefelter's and these other conditions are not well characterized or understood.

In contrast to these potentially increased risks, it is currently thought that rare X-linked recessive conditions occur less frequently in XXY males than in normal XY males, since these conditions are transmitted by genes on the X chromosome, and people with two X chromosomes are typically only carriers rather than affected by these X-linked recessive conditions.

There are many variances within the XXY population, just as in the most common 46,XY population. While it is possible to characterise 47,XXY males with certain body types, that in itself should not be the method of identification as to whether or not someone has 47,XXY. The only reliable method of identification is karyotype testing.

Diagnosis

A karyotype is used to confirm the diagnosis. In this procedure, a small blood sample is drawn. White blood cells are then separated from the sample, mixed with tissue culture medium, incubated, and checked for chromosomal abnormalities, such as an extra X chromosome.

Diagnosis can also be made prenatally via chorionic villus sampling or amniocentesis, tests in which fetal tissue is extracted and the fetal DNA is examined for genetic abnormalities. A 2002 literature review of elective abortion rates found that approximately 50% of pregnancies in the United States with a diagnosis of Klinefelter's syndrome were terminated.[14]

Cause

The extra X chromosome is retained because of a nondisjunction event during meiosis (sex cell division). The XXY chromosome arrangement is one of the most common genetic variations from the XY karyotype, occurring in about 1 in 500 live male births.[4]

In mammals with more than one X chromosome, the genes on all but one X chromosome are not expressed; this is known as X inactivation. This happens in XXY males as well as normal XX females.[15] However, in XXY males, a few genes located in the pseudoautosomal regions of their X chromosomes, have corresponding genes on their Y chromosome and are capable of being expressed.[16] These triploid genes in XXY males may be responsible for symptoms associated with Klinefelter's syndrome.

The first published report of a man with a 47,XXY karyotype was by Patricia A. Jacobs and Dr. J.A. Strong at Western General Hospital in Edinburgh, Scotland in 1959.[17] This karyotype was found in a 24-year-old man who had signs of Klinefelter's syndrome. Dr. Jacobs described her discovery of this first reported human or mammalian chromosome aneuploidy in her 1981 William Allan Memorial Award address.[18]

Variations

The 48, XXYY (male) syndrome occurs in 1 in 18,000–40,000 births and has traditionally been considered to be a variation of Klinefelter's syndrome. XXYY tetrasomy is no longer generally considered a variation of KS, although it has not yet been assigned an ICD-10 code.

Males with Klinefelter syndrome may have a mosaic 47,XXY/46,XY constitutional karyotype and varying degrees of spermatogenic failure. Mosaicism 47,XXY/46,XX with clinical features suggestive of Klinefelter syndrome is very rare. Thus far, only about 10 cases have been described in literature.[19]

Treatment

The genetic variation is irreversible. Testosterone treatment is an option for some individuals who desire a more masculine appearance and identity.[20] Often individuals that have noticeable breast tissue or hypogonadism experience depression and/or social anxiety because they are outside of social norms. This is academically referred to as psychosocial morbidity.[21] At least one study indicates that planned and timed support should be provided for young men with Klinefelter syndrome to ameliorate current poor psychosocial outcomes.[21]

By 2010 over 100 successful pregnancies have been reported using IVF technology with surgically removed sperm material from men with Klinefelter's syndrome.[22]

See also

References

  1. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease. St. Louis, Mo: Elsevier Saunders. pp. 179. ISBN 0-7216-0187-1. 
  2. ↑ Bock, Robert (August 1993). "Understanding Klinefelter Syndrome: A Guide for XXY Males and their Families" (HTML). NIH Pub. No. 93-3202. Office of Research Reporting, NICHD. http://www.nichd.nih.gov/publications/pubs/klinefelter.cfm. Retrieved 2007-04-07. 
  3. ↑ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. p 549. ISBN 0721629210.
  4. ↑ 4.0 4.1 4.2 "Klinefelter Syndrome" (HTML). Health Information. National Institute of Health and Human Development. 2007-02-19. http://www.nichd.nih.gov/health/topics/klinefelter_syndrome.cfm. Retrieved 2007-03-24.  and "Klinefelter syndrome" (HTML). Genetics Home Reference. National Library of Medicine. 2006. http://ghr.nlm.nih.gov/condition%3Dklinefeltersyndrome. Retrieved 2007-03-24.  both provide statistical estimates.
  5. ↑ Klinefelter, HF Jr; Reifenstein, EC Jr; Albright (1942). "Syndrome characterized by gynecomastia, aspermatogenesis without a-Leydigism and increased excretion of follicle-stimulating hormone". J Clin Endocrinol Metab 2: 615–624. doi:10.1210/jcem-2-11-615 . Klinefelter, HF (1986). "Klinefelter's syndrome: historical background and development". South Med J 79 (45): 1089–1093. PMID 3529433  talks about the history of the development of the literature.
  6. ↑ Denschlag, Dominik, MD; Clemens, Tempfer, MD; Kunze, Myriam, MD; Wolff, Gerhard, MD; Keck, Christoph, MD (October 2004). "Assisted reproductive techniques in patients with Klinefelter syndrome: A critical review". Fertility and Sterility 82 (4): 775–779. doi:10.1016/j.fertnstert.2003.09.085. PMID 15482743 
  7. ↑ Graham, JM Jr; Bashir, AS; Stark, RE; Silbert, A; Walzer, S (June 1988). "Oral and written language abilities of XXY boys: implications for anticipatory guidance". Pediatrics 81 (6): 795–806. PMID 3368277 
  8. ↑ Boone KB, Swerdloff RS, Miller BL, et al. (May 2001). "Neuropsychological profiles of adults with Klinefelter syndrome". J Int Neuropsychol Soc 7 (4): 446–56. doi:10.1017/S1355617701744013. PMID 11396547. 
  9. ↑ Abstract of Klinefelter, HF (1986). "Klinefelter's syndrome: historical background and development". South Med J 79 (9): 1089–1093. PMID 3529433  provides information on microorchidism (small testes), hypogonadism (infertility/sterility and androgen hormone function) and gynecomastia. Bock, Robert (August 1993). "Understanding Klinefelter Syndrome: A Guide for XXY Males and Their Families" (HTML). NIH Pub. No. 93-3202. Office of Research Reporting, NICHD. http://www.nichd.nih.gov/publications/pubs/klinefelter.cfm. Retrieved 2007-03-28.  offers substantive information about body type and appearance until a more rigorous source is found/supplied.
  10. ↑ Bock, Robert (August 1993). "Understanding Klinefelter Syndrome: A Guide for XXY Males and Their Families, Adolescence section" (HTML). NIH Pub. No. 93-3202. Office of Research Reporting, NICHD. http://www.nichd.nih.gov/publications/pubs/klinefelter.cfm#xadol. Retrieved 2007-03-29.  describes statistical occurrence of gynecomastia and surgical treatment.
  11. ↑ 11.0 11.1 Leask, Kathryn (October 2005). "Klinefelter syndrome" (HTML). National Library for Health, Specialist Libraries, Clinical Genetics. National Library for Health. http://www.library.nhs.uk/genepool/ViewResource.aspx?resID=104897. Retrieved 2007-04-07. 
  12. ↑ Hultborn, R; Hanson, C; Kopf, I; Verbiene, I; Warnhammar, E; Weimarck, A (1997 November-December). "Prevalence of Klinefelter's syndrome in male breast cancer patients". Anticancer Res. 17 (6D): 4293–4297. PMID 9494523 
  13. ↑ For instance, while Hultborn, R; Hanson, C; Kopf, I; Verbiene, I; Warnhammar, E; Weimarck, A (1997 November-December). "Prevalence of Klinefelter's syndrome in male breast cancer patients". Anticancer Res. 17 (6D): 4293–4297. PMID 9494523  shows a 50-fold increased risk of developing breast cancer versus normal males, study of the SEER Cancer Statistics Review (CSR) databases available at the National Cancer Institute reveal that female relative risk of breast cancer incidence compared to normal males is around a 100 to 200-fold increase, which indicates XXY males may not be as much at risk statistically as normal females are.
  14. ↑ Caroline Mansfield, Suellen Hopfer, Theresa M. Marteau (1999). "Termination rates after prenatal diagnosis of Down syndrome, spina bifida, anencephaly, and Turner and Klinefelter syndromes: a systematic literature review". Prenatal Diagnosis 19 (9): 808–812. doi:10.1002/(SICI)1097-0223(199909)19:9<808::AID-PD637>3.0.CO;2-B. http://www3.interscience.wiley.com/cgi-bin/abstract/65500197/ABSTRACT. PMID 10521836 This is similar to 90% results found by David W. Britt, Samantha T. Risinger, Virginia Miller, Mary K. Mans, Eric L. Krivchenia, Mark I. Evans (1999). "Determinants of parental decisions after the prenatal diagnosis of Down syndrome: Bringing in context". American Journal of Medical Genetics 93 (5): 410–416. doi:10.1002/1096-8628(20000828)93:5<410::AID-AJMG12>3.0.CO;2-F. PMID 10951466
  15. ↑ Chow J, Yen Z, Ziesche S, Brown C (2005). "Silencing of the mammalian X chromosome". Annu Rev Genomics Hum Genet 6: 69-92. PMID 16124854
  16. ↑ Blaschke RJ, Rappold G (2006). The pseudoautosomal regions, SHOX and disease. Curr Opin Genet Dev. Jun; 16:233-9. PMID 16650979
  17. ↑ Jacobs PA, Strong JA (January 31, 1959). "A case of human intersexuality having a possible XXY sex-determining mechanism". Nature 183 (4657): 302–3. doi:10.1038/183302a0. PMID 13632697. 
  18. ↑ Jacobs PA (September 1982). "The William Allan Memorial Award address: human population cytogenetics: the first twenty-five years". Am J Hum Genet 34 (5): 689–98. PMID 6751075. 
  19. ↑ Velissariou V, Christopoulou S, Karadimas C, Pihos I, Kanaka-Gantenbein C, Kapranos N, Kallipolitis G, Hatzaki A. (July - August 2006). "Rare XXY/XX mosaicism in a phenotypic male with Klinefelter syndrome: case report". Eur J Med Genet 49 (4): 331-337. PMID 16829354
  20. ↑ Androgen deficiency and replacement therapy in men - http://www.mja.com.au/public/issues/180_10_170504/han10513_fm.html
  21. ↑ 21.0 21.1 Simm PJ, Zacharin MR (April 2006). "The psychosocial impact of Klinefelter syndrome--a 10 year review". J. Pediatr. Endocrinol. Metab. 19 (4): 499–505. PMID 16759035. 
  22. ↑ Fullerton G, Hamilton M, Maheshwari A. (2010). "Should non-mosaic Klinefelter syndrome men be labelled as infertile in 2009?". Hum Reprod. 2010 Mar;25(3):588-97. Epub 2010 Jan 19. 25 (3): 588–97. doi:10.1093/humrep/dep431. PMID 20085911. 

Further reading

External links

Pathology: chromosome abnormalities (Q90-Q99 · 758)
Autosomal
Trisomies
Down syndrome (21) · Edwards syndrome (18) · Patau syndrome (13)
Trisomy 9 · Warkany syndrome 2 (8) · Trisomy 22/Cat eye syndrome (22) · Trisomy 16
Monosomies/deletions

Wolf-Hirschhorn syndrome (4) · Cri du chat/Chromosome 5q deletion syndrome (5) · Williams syndrome (7) · Jacobsen syndrome (11) · Miller-Dieker syndrome/Smith-Magenis syndrome (17) · DiGeorge syndrome (22)
genomic imprinting (Angelman syndrome/Prader–Willi syndrome (15))

18q deletion syndrome
X/Y linked
Monosomy
Trisomy/tetrasomy,
other karyotypes/mosaics

Klinefelter's syndrome (47,XXY) · 48,XXYY · 48,XXXY · 49,XXXYY · 49,XXXXY

Triple X syndrome (47,XXX) · 48,XXXX · 49,XXXXX

47,XYY · 48,XYYY · 49,XYYYY

46,XX/XY
Translocations
Lymphoid
Burkitt's lymphoma t(8 MYC;14 IGH) · Follicular lymphoma t(14 IGH;18 BCL2) · Mantle cell lymphoma/Multiple myeloma t(11 CCND1:14 IGH) · Anaplastic large cell lymphoma t(2 ALK;5 NPM1) · Acute lymphoblastic leukemia
Myeloid
Philadelphia chromosome t(9 ABL; 22 BCR) · Acute myeloblastic leukemia with maturation t(8 RUNX1T1;21 RUNX1) · Acute promyelocytic leukemia t(15 PML,17 RARA) · Acute megakaryoblastic leukemia t(1 RBM15;22 MKL1)
Other
Ewing's sarcoma t(11 FLI1; 22 EWS) · Synovial sarcoma t(x SYT;18 SSX) · Dermatofibrosarcoma protuberans t(17 COL1A1;22 PDGFB) · Myxoid liposarcoma t(12 DDIT3; 16 FUS) · Desmoplastic small round cell tumor t(11 WT1; 22 EWS) · Alveolar rhabdomyosarcoma t(2 PAX3; 13 FOXO1) t (1 PAX7; 13 FOXO1)
Gonadal dysgenesis
Mixed gonadal dysgenesis · XX gonadal dysgenesis
Other
Fragile X syndrome · Uniparental disomy · XX male syndrome