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Klinefelter's syndrome in identical twins with the 46,XX chromosome constitution
Klinefelter’s Syndrome in Identical Twins with the 46,xX Chromosome Constitution
G. L. NICOLIS, M.D., Ph.D.* L. Y. HSU, M.D. R. SABETGHADAM, M.D. N. B. KARDON, M.D. P. R. CHERNAY, M.D. D. P. MATHUR, M.D. H. G. ROSE, M.D. K. HIRSCHHORN, M.D. J. L. GABRILOVE, M.D. New York, New York
From the Departments of Medicine and Pediatrics, The Mount Sinai Hospital and School of Medicine, New York, New York, and the Department of Medicine, Veterans Administration Hospital, Bronx, New York. This study was supported by Grants AM 11855, HD 00210, HD 02552, HD 02754 and FR-71 from the U.S. Public Health Service. R,equests for reprints should be addressed to Dr. Giorgio Nicolis, Department of Medicine, The Mount Sinai Hospital, 1 East 100th Street, New York, New York 10029. Manuscript received June 24, 1971. *Senior Investigator, New York Hea.rt Association.
482
Two monozygotic
twins with male phenotype had a 46,Xx karyotype in the buccal mucosa, blood, skin and testis. The data in fourteen previously described phenotypic males with the 46,Xx karyotype are reviewed. Although they resemble patients with classic (47,XXY) Klinefelter’s syndrome they tend to be better virilized and often have less severe seminiferous tubular damage. Quinacrine staining of interphase and metaphase nuclei of various tissues failed to demonstrate the presence of a Y chromosome. The reason for the development of testicular structures and a male phenotype in these patients remains speculative. Studies of the abnormalities of the sex chromosomes in man have led to the conclusion that the Y chromosome is strongly male determining. Thus in patients with Klinefelter’s syndrome, the presence of a Y chromosome will result in testicular development and a male phenotype even if there are two, three or four X chromosomes. Conversely, the absence of a Y chromosome will result in a female (or neutral) phenotype even if only one X chromosome is present. Contrary to this rule has been the description since 1964 of fourteen patients with testes and a male phenotype associated with an apparently normal 46,Xx female karyotype [l-12]. These patients basically resemble those with classic (or 47,XXY) Klinefelter’s syndrome, although they tend to be better virilized clinically and often have less severe histologic damage of the seminiferous tubules. An increased incidence of multiple births among patients with the Klinefelter’s syndrome and their families has been noticed since 1962, and nine cases of identical twins with this disorder have been recorded to date. We wish to describe two additional phenotypic males with a 46,Xx karyotype who were also monozygotic twins. CASE
REPORTS
The propositus (H.B. born October 10, surgical service because of enlargement
1921) was admitted to the and discomfort
The Amerkan
Journal
of the left
of Medicine
KLINEFELTER’S
SYNDROME
IN IDENTICAL
TWINS -
NICOLIS
ET AL.
breast of six months’ duration. Preoperative endocrinologic evaluation was requested because he had suffered mild bronchial asthma during the previous six years and had taken glucocorticoids for short periods of time. He had noted bilateral breast enlargement since the age of twenty-five, but the size had not changed until recently. He stated that he had an identical twin brother (D.B.) who also had long-standing gynecomastia. Both parents were apparently normal and had died of unrelated causes. There was no known consanguinity. The mother had two cousins who were identical twins, and one cousin who was mentally deficient. When H.B. and D.B. were born the mother was thirty years old and the father thirty-two. At the age of twenty-six years the mother had given birth to a deformed son who died a few months later. At the age of twenty-eight years she delivered a daughter who is alive and well, and who has two normal children and one mentally retarded child. At the age of thirty-eight years the mother delivered a second deformed son who died two days later. Both twins had developed normally until puberty. They had been average students and had graduated from college. After discharge from the Army they had worked for ten years in a construction firm and had later started their own heating and air conditioning contracting firm. In both twins some pubic hair had appeared at the age of fifteen and facial hair at the age of seventeen. Since age nineteen they had been shaving regularly every other day. Neither had any appreciable axillary or thoracic hair. After puberty there were no spontaneous erections or desire for sexual activity, although H.B. had sexual intercourse a few times while in the Army. Both patients married at the age of twenty-seven and had regular sexual intercourse with ejaculation about three times a week for the next six to seven years. Since then sexual relations with their spouses had become progressively less frequent, and H.B. had not had intercourse during the year preceding admission. D.B. was having intercourse about once a week at the time of admission. There were no children from either marriage. Both patients began to gain weight in their late twenties. The remaining medical history was negative except that D.B. had undergone appendectomy at age forty-one. H.B. was 65 inches tall, his span 64 inches, pubis to heel 32 inches and weight 164 pounds. Blood pressure, pulse rate and respiration were normal. The skin of the face was finely wrinkled, but the facial hair was only modestly decreased in density, and distribution was normal. The voice had a masculine pitch. Thoracic and axillary hair were absent. Pubic hair was sparse with a horizontal upper border. There was moderate, slightly tender, bilateral gynecomastia. It was more pronounced on the left where an ill defined 2 by 2 cm mass extended into the upper outer quadrant, There was diffuse late expiratory wheezing over both lung fields, and a grade 2/6 holosystolic murmur was heard at the car-
Volume 52, April 1972
Figure 1. The propositus to the right.
H.B. is to the left of viewer, D.B.
disc apex radiating into the axilla. The penis was 6.0 cm long with a normally placed urethral meatus. The scrotum was normally pigmented and rugated. The testes were about 1.0 cm long. The prostate was small. The epididymi, vasa deferentia and seminal vesicles could be identified by palpation. The musculature and the distribution of the adipose tissue were of normal male type. The second twin (D.B.) was remarkably similar in appearance (Figure 1). He was 1 inch taller and noticeably more obese (180 pounds), but he had the same skeletal proportions and the same primary and secondary sexual characteristics. His heart and lungs were normal. There was bilateral gynecomastia which was not tender and showed no discrete masses. The dermatoglyphic analysis of both patients is shown in Table I. The finger and palm patterns were unremarkable except for the resemblance to each other. LABORATORY
STUDIES
Laboratory evaluation was essentially that both patients had elevated serum
negative except cholesterol and
483
KLINEFELTER’S
TABLE
I
SYNDROME
IN IDENTICAL
Dermatoglyphic
TWINS-NICOLIS
Analysis
TABLE II
Finger and Palm Patterns 123
Hand
4
ET AL
5
S.L. A.T.
.
Is
I(
Hp
Total Finger Ridge Count -
Patient H.B. R L
www w L”
w w
w
w w
0 0
t’ t’
L‘j 0
0 0
0 0
Ld 0
0 L”
0 0
151
Patient D.B. R L
L” w
w w
w w
w w
w L”
0 0
t’ t’
._.
158
NOTE: R = right: L = left. W = whorl; L, = ulnar loop; Ld = distal loop; S.L. = simian line; A.T. = axial triradius; II = third interdigital Hp = hypothenar
TABLE III
pattern; pattern;
I( = fourth 0 = absent.
pattern;
of
Cortisol Patient
vena
cava
4.4
Patient
Left adrenal
475.0
* Radioimmunoassay:
courtesy Hospital,
Columbia-Presbyterian
dione
Estradiol* --
0.119 0.167 1.065
0.00075 0.00287 0.00148
0.157 0.194
0.00130 0.00368
4.706 .-
0.00176 .-
D.B.
23.8 19.1
vein .-.
terone
0.047 0.623 0.066
114.0
Inferior vena cava Left spermatic vein
Estrone and
H.B.
7.7
Left spermatic vein Left adrenal vein
Testos-
Androstene-
0.056 0.947 0.118
of Dr. lnga Dyzenfurth, New York, N.Y.
triglyceride levels* (Table II). The results of the endocrinologic studies are shown in Tables II and III. Chest films, skeletal survey and excretory urogram were normal as was the electrocardiogram. l.Q.+ was 93 for H.B. and 100 for D.B.+ In both patients testicular biopsy specimens showed advanced changes characteristic of adult patients with chromatin-positive Klinefelter’s syndrome. The seminiferous tubules were totally obliterated and hyalinized. They were often difficult to recognize and contained no cellular elements. The Leydig cells were diffusely hyperplastic with occasional adenoma-like clumping (Figures 2 and 3). The H.B.
breast
showed
specimen
ductal
removed
proliferation
at
mastectomy
with multilayered
from
epi-
* The increase in serum lipids resulted from increased levels of both low density lipoproteins (LDLP-TC; H.B. = 220 mg per cent; D.B. = 224 mg per cent) and very low density lipoproteins (VLDLP-TC; H.B. = 55.8 mg per cent; D.B. = 87.6 mg per cent). t Wechsler adult intelligence scale.
484
Studies
Results Patient H.B.
Determination Serum Total
cholesterol
(mg
Triglycerides (mg %) Protein-bound iodine T, resin uptake index Plasma (Irg %) Cortisol (391 Testosterone
%) (pg %)
7.7 0.068
sulfate
(41)
fig/24
hr) [43]
Ejaculate Volume (ml.) Spermatozoa Thyroid
D.B.
372 294 4.7 1.06 10.0 0.039 0.157
sulfate
Urine 17-hydroxycorticoids (mg/24 hr) 17-ketosteroids (mg/24 hr) Total gonadotropin (mouse units/ 24 hr) Testosterone glucuronide &g/24 (EI/E2/EJ
Patient
0.082
1411
hr) (421 Estrogens
345 331 5.1 0.99
1401
Androstenedione [40] Dehydroepiandrosterone Androsterone
Hormonal Steroids in the Inferior Vena Cava and in the Adrenal and Spermatic Veins -Plasma Concentration (pg %)
Simultaneous Catheterization
Inferior
interdigital
Results of Laboratory
65.9
81.9
12.9
39.4
6.1 9.0
7.1 9.4
>20
<50
>20
<50
43.9
35.0
81-14
10/o/3
0.7 None
1.0 None
function
lJ1l uptake (%/24 hr) Thyroidal clearance (ml/min)
17 19
... . *.
lining of the ducts (Figure 4). The ducts were surrounded by the characteristic cuffs of loose connective tissue which are commonly seen in cases of gynecomastia of relatively recent onset [13]. The interlobular stroma was made up by fibroblastic rather vascular connective tissue. Leukocyte typing for the HL-A3, HL-A9, R* and Te58 antigens gave an A match. In addition, the patients had the following blood groups in common: Al+, A+, B--, thelial
D+, CS, E-, ct, e+, CW-, Ps, K-, kf, K;-, K”+, M-, N+, S-, s+, Lua-, Fy”+, Jka+. (Dr. D. M. Fotiho, The New York Blood Center.) CYTOGENETIC
STUDIES
The buccal smears of both patients showed 27 per cent of nuclei containing one sex chromatin body of normal size. Their oral mucosa cells were stained with quinacrine mustard as described by Caspersson et al. [14] and by Pearson et al. [15]. In over 200 nuclei examined, no fluorescent body was detected. Seven per cent of the Leydig cells in the testicular biopsy specimen of H.B. and 11 per cent of the Leydig cells of D.B. were chromatin-positive. Chromosome analyses were performed on cultures of peripheral leukocytes, skin and testicular fibro-
The American
Journal of Medicine
KLINEFELTER’S
Figure 2.
Testicular
bio,psy specimen
from
H.6.
SYNDROME
Testicular
Figure 3.
IN IDENTICAL
biopsy
Chromosome
TABLE IV
TWINS -
specimen
Analysis
NICOLIS
ET AL
from D.B.
of Tissue Cultures
ChromosomeCount 45
Culture
46
47
20 20 20
0 0 0
0
20
0
0
20
0
Patient
Patient Blood Skin
Figure 4.
Breast
biopsy specimen
from H.B.
blasts. These studies revealed a 46,Xx constitution in all tissues studied (Table IV). The metaphases of these cultures were stained with quinacrine dihydrochloride [15]. No brightly fluorescent Y chromosome was identified. In addition there was no abnormally brightly fluorescent region on any other chromosome which could be interpreted as a translocation of the distal portion of the long arm of the Y. The karyotype of H.B. stained with quinacrine dihydrochloride is shown in Figure 5. The metaphases of both patients were also studied by the differential staining technic of Arrighi and Hsu [16]. With this technic, the deoxyribonucleic acid (DNA) is first denatured with sodium hydroxide and then partially renatured with sodium citrate buffer. The basis of the differential staining is that the repetitive DNA which has renatured most rapidly combines better with the stain. The Y chromosome is readily identifiable by the dense staining of the distal two-thirds of the long arm. The other chromosomes also show characteristic
Volume 52, April
1972
H.B.
0 0 0
Blood Skin Testis
D.B.
centromeric staining [17]. By this technic no densely stained segment of the Y chromosome was detected. The karyotype of D.B. stained with this technic is shown in Figure 6.
COMMENTS Nelson patients tures
and with may
Heller
[18]
Klinefelter’s vary
first
recognized
syndrome
considerably,
that
clinical
especially
in fea-
those
reflect Leydig cell function. Thus, the disorder encompasses a spectrum that ranges from subjects who are severely eunuchoidal to those who are fully virilized. With the advent of chromosomal analysis, however, it has become apparent that some of the patients with karyotypes that differ from the classic 47,XXY form of the disorder may have distinguishing clinical features. For example, patients with the 48,XXXY and the 48,XXYY karyotypes are characterized by the consistent presence of mental deficiency. Those with the 49,XXXXY karyotype, in addition to being mentally deficient, often show short stature, small genitalia, undescended testes and skeletal malformawhich
485
KLINEFELTER’S
SYNDROME
IN IDENTICAL
TWINS -
NICOLIS
ET AL.
tions. Mosaics with a normal 46,XY testicular cell line may have virtually normal gonadal function [19-211. It can be seen from Table V that phenotypic males with the 46,Xx karyotype have the essential features of Klinefelter’s syndrome. The testes were invariably small and all but one patient (Case 13) had azoospermia. Exploratory laparotomy was carried out in two patients and disclosed normal Wolffian structures and no abnormal Miillerian remnants. In most of the other cases the epididymis, the vasa deferentia, the prostate and the seminal vesicles were described as being clearly normal at palpation. In all cases the urethra had a normal meatus. Two patients had unilaterally undescended testes, one was considered
to be mentally deficient, and no skeletal anomalies were present. The mean maternal age (28.3 years) was not significantly different (p >O.OS) than that found by Friiland [20] for forty-one Danish patients (32.3 years) and by Court Brown et al. [3] for eighty-three Scottish patients (32.5 years) with chromatin-positive Klinefelter’s syndrome. A majority of the investigators who have reported previous cases [1,2,4-6,9,1 l] have remarked that their patients with the 46,Xx karyotype differed in some respects from those with the classic form of the disorder. In most cases the habitus was typically male. Facial hair was normal. There was no gynecomastia. The urinary gonadotropins were normal, and the testicular histology showed relatively little tubular damage. The pub-
Quinacrine dihydrochloride Figure 5. stain of karyoiype from H.B. (top) compared to normal male (bottom). Skin.
486
The American
Journal of Medicine
KLINEFELTER’S
lished males
degree present
photographs support the impression that with the 46,Xx karyotype tend to be better
-
7
13 -
-
14 -
lo
%Q
I9
- 20
8
I5
-
9
-
II
-
12
I6
I7
-
I8
ifii;u
b’
t0
21
IN IDENTICAL
of Leydig cell in all patients.
TWINS -
hyperplasia,
NICOLIS
however,
ET AL.
was
Azoospermia was present in all but one patient (Case 13) who had spermatozoa in his urine. His testicular histology and karyotype were not studied, however, and it seems possible that he was a mosaic with a normal 46,XY cell line in the testis like the patients described by Lindsten et al. [6] and by Brb;gger and Aagenaes [23]. Also of note is that urinary gonadotropin levels were clearly elevated in only three patients [6,8,9], questionably in two [1,13] and normal in seven ([2,7,10,11,12] and our two). In classic Klinefelter’s syndrome, urinary gonadotropin levels are almost invariably elevated as was the case, for example, in 94 per cent of the cases reported by
virilized than those with the 46,XXY karyotype. However, the already mentioned variability of this feature in Klinefelter’s syndrome, together with the small number of patients described to date, make it difficult to separate the males with the 46,Xx karyotype into a distinct variant form. The testicular histopathology of phenotypic males with the 46,Xx karyotype was considered typical of chromatin-positive Klinefelter’s syndrome in eight cases ([3,6,7,9,11,14] and our two). In the six other cases [1,2,5,8,10,12] in which data are available the tubular damage was distinctly less severe, and the histologic picture was similar to that seen in patients with germinal cell aplasia [22]. Some
-6
SYNDROME
-.
-22
Y
-6-7-8-9-1O;II-I2
l3-
19
l4-
I! - 20
Volume 52, April 1972
15
-16
21
I7
-22
-
I8 II Y
Figure
6. Differential DNA stain of karyotype from D.B. (top) compared to normal male (bottom). Peripheral blood.
487
KLINEFELTER’S
TABLE V
SYNDROME
Clinical
IN IDENTICAL
and Laboratory
Findings
De La Chapelle et al. 1964 [l]
Data
TWINS-
NICOLIS
ET AL.
in 46, XX Males
Therkelsen 1964 [2]
Court Brown et al. 1964 [3j
De La Chapelle et al. 1411965
Strauch et al. 1965 [5j
Lindsten et al. 1966 [S]
Patients’ &
3:
(yr)
1:
2:
Age
Maternal Paternal
Mr;;rtments
25 0
26 31
(cm) 172 91.5 174
Lo&r segment Span Hair Facial ;;;;ry
Absent
N
2.5, 1.0 cm 0
Ejaculate
Low Normal 14
Intelligence Puberty (age) 17-ketosteroids
9.8-6.3
(mg/24 hr) W5/EI (424 hr)
aH-thymidine autoradiography Testicular histology
0 Slightly hypoplastic 3.0 cm
4cm
Testes
Chromosomal. analysis
Sparse N N -
! -
Gynecomastia Prostate Penis
Gonadotropins [MU/24 hr) Sex chromatinpositive
167 0 0
167
154
1::
1::
N
N
Absent
scaNnty
I! +
scaNnty -
+ 0 N 2.0 cm
Small
Small
Subnormal Moderate hypoplasia Very small
-
0
0
0
N 14
0 0 0
0 0 0
N N 6.5
7.0-8.9 (20-50 MU; N)
0
0
0
0
>40;
69-72 (N)
0
0
0
>lOO
Buccal mucosa leukocytes
Buccal mucosa skin, testis
Buccal mucosa
Buccal mucosa leukocytes Blood, skin
0.65/0.0/3.1
Blood, bone marrow, peritoneum, skin, fascia, testis Leukocytes
Blood, skin, testis
1
Blood, skin
-
-
Tubular hyalinization with some Sertoli cells: ;t-iig
Mild peritubular fibrosis; Sertoli cells and spermatogonia in tubules; Leydig cell hyperplasia
No hyalinization; mild peritubular fibrosis; Sertoli cells in tubules; Leydig cell hyperplasia
Athletic; normal internal male structures at laparotomy
Normal male habitus; Sertoli cells chromatin negative
...
= absent;
no information;
N = normal.
0
Buccal mucosa
Buccal mucosa skin, testis
N Subnormal Prepuberal 0
NOTE: + = present:
488
-
0 =
...
+I SF
N Prepuberal 5.4-7.7 2.6/0.7/1.9 >13 <53 Buccal mucosa skin, testis
8.# (< >s But n S tc
Blood, skin, testis
+
Blood, skin, testls
Blood, skin, testis
Blo
Skin
Skin, leuko. cytes
Let
Gel
Tubules with slightly thickened walls and Sertoli cells; Leydig cell hyperplasia
Diffuse tubular sclerosis; rare Sertoli II cerrs; Leydig cell hyperplasia
50% tubular sclerosis; 50% tubules with Sertoli II cerrs; Leydig cell hyperplasia
Normal male habitus
“Very masculine and hairy”
Normal male structures at laparotomy: DNA content of sex chromatin equal to normal female; atd angles similar to Turner’s syndrome
present Miscellaneous
1.
The
American Journal
of
Medlclne
Sl
C
C
s t S
KLINEFELTER’S
t et al. 6 171
DeGrouchyet al. 1966]8]
4; 39 40 67 6: arse anty N -
36
34
23 0
:
18 0
157 84 0
170 92 0
Absent N N -
N
8cm
?rries
Small
N N i.8
0
:
N N
N N
1.5 cm
2.0 cm; R. undescended 0
Deficient 0 5.3-11.2
I.Q. 96 14 7.2
16
x 0 + 0 0 R. undescended
0
0
0
0
>6
0
0
Buccal m ucosa
skin, s
Blood, testis
Blood, testis
Blood, skin, testis
Blood, skin
Blood, skin
:ytes
-
-
Leukocytes
Leukocytes
Thickening of basement membrane; Sertoli cells, few spermatogonia, spermatocytes; Leydig cell hyperplasia
Tubules hyalinized; Leydig cell hyperplasia
Tubules 70% sclerosed; 30% with Sertoli cells: moderate Leydig cell hyperplasia
0
Feminine fat distribution
Sertoli cells chromatin negative; atd angles and total ridge count similar to Turner’s syndrome; quinacrine stain of bone marrow and blood cultures
‘Sperm in urine,” “patent ductus arteriosus,” “quite masculine”
..
Volume
52,
April
1972
lnguinal
0 0 0
0
Buccal mucosa
?S :ult to gnize; lig ceil xplasia
: 0 0 0 0
0
Buccal mucosa, Leydig ceils
osa
17
30 32
x
0 0 4.0
Buccal mucosa
I
13.2
ET AC.
49
30 32
0
Buccal mucosa
>5 125
15 7 mo
a
4.0/0.0/7.3
35
NICOLIS
0 8 0
5 Ag (follic. ulin) <50 >25
.5/1.7
TWINS-
Nicolis et al. 1971
Chin
Small N
+ (azoospermia)
IDENTICAL
George,Polani 1970 1121
165
! -
0
IN
:
!
Almonds
1.0. 91 Prepuberal 3.0
24
I!! N
0
bosper-
163
Powers et al. 1970 [ll]
i Feminine
0
IUVl
Boczkowsky et al. 1969 ]9,10]
SYNDROME
0
“Klinefefterlike”
N Absent Scanty + Small 6cm
N Absent Scanty
1.0
1.0 cm
cm
0.5 cc (azoospermia) I.Q. 93 14 9.0 8/-/4
1.0 cc(azoospermia) I.Q. 100 14 9.4 10/O. G/3
>20 <50
>20 <50
Buccal mucosa
Buccal mucosa, Leydig cells
Blood, skin
Blood, skin, testis
Buccal mucosa, Leydig cells Blood, skin
0
N hyalinization; Leydig cell hyperplasia
Quinacrine stain, blood and skin culture
+ Small 6cm
Quinacrine stain, blood and skin culture
Complete tubular hy aiinization; Leydig cell hyperplasia
Quinacrine and Quinacrine differential and differDNA stains; ential DNA buccal mucosa; stains: skin leukobuccal cytes and mucosa; testis cultures skin and leukocytes cultures
489
KLINEFELTER’S
SYNDROME
IN IDENTICAL
TWINS -
NICOLIS
ET AL.
Paulsen et al. [24] and in 78 per cent of those reported by Becker et al. [25]. Since plasma testosterone has not been previously measured in male subjects with the 46,Xx karyotype, no objective proof exists of the clinical impression that their Leydig cell function may be better maintained than in most patients with classic Klinefelter’s syndrome. In our two patients plasma testosterone was low and considerably lower than the mean found by Paulsen et al. [24] in twenty patients with the chromatin-positive Klinefelter’s syndrome (mean 0.280 pg per cent; range 0.04 to 0.88 pg per cent). Although the plasma testosterone level in our patients was in the female range it appeared to derive mostly from testicular secretion rather than the peripheral conversion of other androgens as is the case in the normal female [26]. This was shown by a gradient in the concentration of testosterone between the spermatic vein and the general circulation (Table Ill) similar to that found by us [27] in normal men. Several possibilities could explain the development of male gonads in the presence of the 46,Xx karyotype: (1) mosaicism with an undetected XXY cell line; (2) loss of a Y chromosome from an original XXY zygote during early embryonic life; (3) undetected Y translocation, and (4) X-Y interchange during paternal meiosis. The last possibility, suggested by Ferguson-Smith [28], is supported by the observation that two of the males with the 46,Xx karyotype [1,4] were Xg a- as were their mothers, whereas their fathers were Xg a+. The failure, of males with XX sex chromosomes to inherit any Xg a allele from the Xg a+ fathers suggests an X-Y interchange during paternal meiosis. This interchange would result in the exchange of male detemining loci from the Y chromosome for the region containing the Xg a gene in the short arm of the X chromosome. The possibility of an original XXY zygote with early loss of a Y chromosome is also compatible with the Xg data since both X chromosomes of males with XX sex chromosomes could have derived from the ,mother by meiotic nondisjunction. However, this requires three abnormal events: (1) the production of an XXY zygote, (2) the loss of a Y during early embryonic development by anaphase lag and (3) the loss of the XXY line after the second event. From the philosophic point of economy of nature this sequence is less likely than the single event of X-Y interchange. The absence of a fluorescent Y in interphase and metaphase cells of our two patients as well as in three previously reported males
490
with XX chromosomes [10,12,29] does prove Ferguson-Smith’s hypothesis. It cently been shown [30] that the specific
not dishas restaining involves the distal heterochromatic portion of the long arm of the Y chromosome. At the same time it seems clear that the male determining genes are located on the short arm of the Y chromosome [31,32] and that this is the portion which associates with the X chromosome during the first meiotic metaphase [33,34]. The short arm of the Y chromosome does not carry a characteristic fluorescent banding pattern nor specific staining properties by the differential staining technic, Therefore, any translocation or interchange involving the short arm of the Y chromosome cannot be identified by the present methods. An increased frequency of twin births in the families of patients with Klinefelter’s syndrome was first noted by Hdfnagel and Benirschke [35] and later confirmed by Nielsen [36]. The latter investigator analyzing the families of twenty patients with the XXY karyotype and of five patients with the XV/XXV karyotype found an incidence of multiple births of 5.59 per cent or 3.4 times the expected. The twin births associated with the Klinefelter’s syndrome may involve relatives, siblings or the patients themselves. In the latter case the twin may be a normal fraternal or an identical twin with the same chromosomal abnormality. The data in the eight cases of identical twins with the chromatin-positive Klinefelter’s syndrome published before 1968 have been reviewed by Vague et al. [37], and a further case was described by Klotz et al. [38] in 1969. Since advanced maternal age is known to be linked with an increased incidence of both the Klinefelter’s syndrome and multiple births, it was initially thought that this explained the association of two disorders. However, Nielsen [36] pointed out that the incidence of twin births in families of patients with Klinefelter’s syndrome is greater than expected even if correction is made for maternal age and that a different mechanism must be operative. Although the nature of this mechanism is not clear at present the high frequency of twins in the sibships with Klinefelter’s as well as Turner’s syndrome indicates a relation between the causes of sex chromosome nondisjunction and of multiple births [36]. ACKNOWLEDGMENT We are grateful to Miss Dora Brenholz, Mrs. Erlinda Conception, Miss Enid Kutinsky and Mrs. Gloria Vanderburg for technical assistance.
The ‘American Journal of Madiclne
KLINEFELTER’S
SYNDROME
IN IDENTICAL
TWINS-
NICOLIS
ET AL.
REFERENCES 1.
2. 3.
4.
5.
6.
7.
8.
9.
10.
De La Chapelle A, Hortkng H, Niemi M, Wennstrdm J: XX sex chromosomes in a human mal,e. Acta Med Stand 412 (suppl): 25, 1964. Therkelsen AJ: Sterile man with the chromosome constitution 46 XX. Cytogenetics 3: 207, 1964. Court Brown WM, Harnden DG, Jacobs PA, Maclean N, Mantle DJ: Abnormalities of the sex chromosome complement in man. Med Res Council Spec Rep Ser No. 305, 1964. De La Chapelle A, Hortling H, Wennstriim J, Niemi M, Johansson CJ: Two males with female chromosomes. Acta Endocr (Kbh) 100 (suppl): 90, 1965. Strauch G, Engel E, Taft PD, Atkins L, Forbes AP: Syndrome de Klinefelter a’ karyotype 46 XX aux niveaux cutane, sanguin et testiculaire. Ann Endo,cr (Paris) 251: 727, 1965. Lindsten J, Bergstrand CG, Tillinger H, Schwarzacher G, Tiepolo L, Muldal S, Hdkfelt B: A clinical and cytogenetical study of three patients with male phenotype and apparent XX sex chromosome constitution. Acta Endocr (Kbh) 52: 91, 1966. Mulert L. von Schrtjter R. Wolf U: Weiblicher Chro’mosomensatz bei einem Mann ohne Hodentubuli. Deutsch Med Wschr 91: 2159, 1966. De Grouchy J, Canivet J, Canlorbe P, Mantel 0, Borniche P, Poitout M: Deux observations d’hommes 46 XX. Ann G&&t (Paris) 10: 193, 1967. Boczkowsky K, Janczewski Z, Philip J, Mikkelsen M: A clinical and cytogenetical study of XX male. Hereditas 62: 285, 1969. Philip J, Nielsen H, Skakkebaek N, Boczkowsky K: Testing the hypothesis of Y translocation in XX males by fluorescence microscopy after quinacrine-dihydrochloride staining. Lancet 1: 298,
1971. 11.
12. 13.
14.
15.
16.
17.
18.
19. 20. 21. 22.
Powers HO, Neu RL, Smulyan H, Gardner LI: An a’dult phenotypic male with a 46,Xx chromolsome complement. J Clin Endocr 31: 567, 1970. George KP, Polani PE: Y heterochromatin and XX males. Nature (Lo,ndon), 228: 1215, 1970. Nicolis GL, Modlinger R, Gabrilove JL: A study of the histopathology of human gynecomastia. J Clin Endocr 32: 173, 1971. Caspersson T, Zech L, Johansson C: Differential binding of alkylating fluorochromes in human chromosomes. Exp Cell Res 60: 315, 1970. Pearson PL, Bobrow M, Vosa CG: Technique for identifying Y chromosomes in human interphase nuclei. Nature (London) 226: 78, 1970. Arrighi FE, Hsu TC: Localization of heterochromatin in human chromosomes. Cy-togenetics 10: 81, 1971. Chernay PR, Hsu LY, Hirschhorn K: Human chromosome identificatio,n by differential stainmg. (Abstract p 123), Program of 41st knnual Meeting of the Society for Pediatric Research. Atlantic City, April 30, 1971. Heller CG, Nelson WO: Hyalinization of the seminiferous tubules associated with normal or failing Levdia-cell function. J Clin Endocr 5: 1. 1945. OverzierC: Intersexuality. New Yo’rk: Academic Press, 1963, p 227. Froland A: Klinefelter’s syndrome. Danish Med Bull 16 (suppl VI): 1, 1969. Paulsen CA: Textbook of Endocrinology (Williams RH, ed), Philadelphia, W. B. Saunders, 1968. Del Castillo EB, Trabucco A, De La Balze FA: Syndrome produced by the absence of the germinal epithelium without impairment of the Sertoli cells or the Leydig cells. J Clin Endocr 7: 493, 1947.
Volume 52, April 1972
23.
24.
25.
26.
27. 28.
29.
30.
31.
32.
33.
34.
35. 36. 37.
38.
39.
40.
41.
42.
43.
Brijgger A, Aagenaes 0: The human Y chromosome and the etiology of true hermafroditism. Hereditas 53: 231, 1965. Paulsen CA, Gordon DL, Carpent,er RW, Gandy HM, Drucker WD: Klinefelter’s syndro,me and its variants. Recent Progr Hormone Res 24: 321, 1957. Becker KL, Hoffman DL, Albert A, Underdahl LO, Mason HL: Klinefelter’s syndrome. Clinical and laboratory findings in 50 patients. Arch Intern Med (Chicago) 118: 314, 1966. Horton R, Tait JF: Androstenedione production and interconversion rates measured in peripheral blood and studies on the possible site of its conversion to testosterone. J Clin Invest 45: 301, 1966. Nicolis ‘GL, Gabrilove JL: Unpublished observations. Ferguso’n-Smith MA: X-Y chromosomal interchange in the etiology o’f true hermaphroditism and of XX Klinefelter’s syndrome. Lancet 1: 475, 1966. Fraccaro M, Tiepolo U, Zuffardi 0, Barigozzi C, Dolfini S: Fluorescence and Y translocation in XX males. Lancet 1: 858, 1971. George KP: Cytochemical differentiatio’n along human chromosomes. Nature (Lon’don) 226: 80, 1970. Jacobs PA, Ross A: Structural abnormalities of the Y chromosome in man. Nature (London) 210: 352,1966. Borgaonkar DS, Hollander DH: Quinacrine fluorescenc,e of the human Y chromosome. Nature (London) 230: 62, 1971. Pearson PL, Bobrow M: Definitive evidence for the short arm of the Y chromo’some associating with the X chromosome during meiosis of the human male. Natur,e (London) 226: 959, 1970. Chen ATL, Falek A: Definitive cytological evidence for the association of the short arms of the X and Y chromosomes. Amer J Human Genet 22: 459,197o. Hdfnagel D, Benirschke K: Twinning in Klinefelter’s syndrome. Lancet 2: 1282, 1962. Nielsen J: Twins and Klinefelter’s syndrome. Acta Genet Med (Roma) 17: 385, 1968. Vague J, Boyer J, Nicolino A, Mattei J, Luciani A, Arnaud A, Pouch J, Vallett,e A: Maladie de Klinefelter chez deux jumeaux monozygotes. Ann Endocr (Paris) 29: 709, 1968. Klotz HP, B,oiffi’n A, Mignot J, Larget B, Lelievre H: Maladie de Klinefelber chez deux jumeaux monozygotes. Ann Endocr (Paris) 30: 86, 1969. Murphy BEP: Some studies on the protein binding of steroids and their application to the routine measurement of various steroids. J Clin Endocr 27: 973, 1967. Kirschner MA, Koffman GD: Measurement of plasma testosterone and androstenedione using electron capture gas-liquid chromatography. J Clin Endocr 28: 1347, 1968. Rosenfeld RS, Hellman L: Measurement of solvolyzable esters of androsterone and dehydroisoandrosterone in human plasma. Steroids 14: 675, 1969. Gabrilove JL, Nicoks GL, Hausknecht RU: Urinary testosterone, oestrogen production rates and urinary oestrogen in chromatin positive Klinefelter’s syndrome. Acta Endocr (Kobenhavn) 63: 499, 1971. Brown JB: A chemical method for the determination of oestriol, oestrone and oestradiol in human urine. Biochem J 60: 185. 1955.
491
G. L. NICOLIS, M.D., Ph.D.* L. Y. HSU, M.D. R. SABETGHADAM, M.D. N. B. KARDON, M.D. P. R. CHERNAY, M.D. D. P. MATHUR, M.D. H. G. ROSE, M.D. K. HIRSCHHORN, M.D. J. L. GABRILOVE, M.D. New York, New York
From the Departments of Medicine and Pediatrics, The Mount Sinai Hospital and School of Medicine, New York, New York, and the Department of Medicine, Veterans Administration Hospital, Bronx, New York. This study was supported by Grants AM 11855, HD 00210, HD 02552, HD 02754 and FR-71 from the U.S. Public Health Service. R,equests for reprints should be addressed to Dr. Giorgio Nicolis, Department of Medicine, The Mount Sinai Hospital, 1 East 100th Street, New York, New York 10029. Manuscript received June 24, 1971. *Senior Investigator, New York Hea.rt Association.
482
Two monozygotic
twins with male phenotype had a 46,Xx karyotype in the buccal mucosa, blood, skin and testis. The data in fourteen previously described phenotypic males with the 46,Xx karyotype are reviewed. Although they resemble patients with classic (47,XXY) Klinefelter’s syndrome they tend to be better virilized and often have less severe seminiferous tubular damage. Quinacrine staining of interphase and metaphase nuclei of various tissues failed to demonstrate the presence of a Y chromosome. The reason for the development of testicular structures and a male phenotype in these patients remains speculative. Studies of the abnormalities of the sex chromosomes in man have led to the conclusion that the Y chromosome is strongly male determining. Thus in patients with Klinefelter’s syndrome, the presence of a Y chromosome will result in testicular development and a male phenotype even if there are two, three or four X chromosomes. Conversely, the absence of a Y chromosome will result in a female (or neutral) phenotype even if only one X chromosome is present. Contrary to this rule has been the description since 1964 of fourteen patients with testes and a male phenotype associated with an apparently normal 46,Xx female karyotype [l-12]. These patients basically resemble those with classic (or 47,XXY) Klinefelter’s syndrome, although they tend to be better virilized clinically and often have less severe histologic damage of the seminiferous tubules. An increased incidence of multiple births among patients with the Klinefelter’s syndrome and their families has been noticed since 1962, and nine cases of identical twins with this disorder have been recorded to date. We wish to describe two additional phenotypic males with a 46,Xx karyotype who were also monozygotic twins. CASE
REPORTS
The propositus (H.B. born October 10, surgical service because of enlargement
1921) was admitted to the and discomfort
The Amerkan
Journal
of the left
of Medicine
KLINEFELTER’S
SYNDROME
IN IDENTICAL
TWINS -
NICOLIS
ET AL.
breast of six months’ duration. Preoperative endocrinologic evaluation was requested because he had suffered mild bronchial asthma during the previous six years and had taken glucocorticoids for short periods of time. He had noted bilateral breast enlargement since the age of twenty-five, but the size had not changed until recently. He stated that he had an identical twin brother (D.B.) who also had long-standing gynecomastia. Both parents were apparently normal and had died of unrelated causes. There was no known consanguinity. The mother had two cousins who were identical twins, and one cousin who was mentally deficient. When H.B. and D.B. were born the mother was thirty years old and the father thirty-two. At the age of twenty-six years the mother had given birth to a deformed son who died a few months later. At the age of twenty-eight years she delivered a daughter who is alive and well, and who has two normal children and one mentally retarded child. At the age of thirty-eight years the mother delivered a second deformed son who died two days later. Both twins had developed normally until puberty. They had been average students and had graduated from college. After discharge from the Army they had worked for ten years in a construction firm and had later started their own heating and air conditioning contracting firm. In both twins some pubic hair had appeared at the age of fifteen and facial hair at the age of seventeen. Since age nineteen they had been shaving regularly every other day. Neither had any appreciable axillary or thoracic hair. After puberty there were no spontaneous erections or desire for sexual activity, although H.B. had sexual intercourse a few times while in the Army. Both patients married at the age of twenty-seven and had regular sexual intercourse with ejaculation about three times a week for the next six to seven years. Since then sexual relations with their spouses had become progressively less frequent, and H.B. had not had intercourse during the year preceding admission. D.B. was having intercourse about once a week at the time of admission. There were no children from either marriage. Both patients began to gain weight in their late twenties. The remaining medical history was negative except that D.B. had undergone appendectomy at age forty-one. H.B. was 65 inches tall, his span 64 inches, pubis to heel 32 inches and weight 164 pounds. Blood pressure, pulse rate and respiration were normal. The skin of the face was finely wrinkled, but the facial hair was only modestly decreased in density, and distribution was normal. The voice had a masculine pitch. Thoracic and axillary hair were absent. Pubic hair was sparse with a horizontal upper border. There was moderate, slightly tender, bilateral gynecomastia. It was more pronounced on the left where an ill defined 2 by 2 cm mass extended into the upper outer quadrant, There was diffuse late expiratory wheezing over both lung fields, and a grade 2/6 holosystolic murmur was heard at the car-
Volume 52, April 1972
Figure 1. The propositus to the right.
H.B. is to the left of viewer, D.B.
disc apex radiating into the axilla. The penis was 6.0 cm long with a normally placed urethral meatus. The scrotum was normally pigmented and rugated. The testes were about 1.0 cm long. The prostate was small. The epididymi, vasa deferentia and seminal vesicles could be identified by palpation. The musculature and the distribution of the adipose tissue were of normal male type. The second twin (D.B.) was remarkably similar in appearance (Figure 1). He was 1 inch taller and noticeably more obese (180 pounds), but he had the same skeletal proportions and the same primary and secondary sexual characteristics. His heart and lungs were normal. There was bilateral gynecomastia which was not tender and showed no discrete masses. The dermatoglyphic analysis of both patients is shown in Table I. The finger and palm patterns were unremarkable except for the resemblance to each other. LABORATORY
STUDIES
Laboratory evaluation was essentially that both patients had elevated serum
negative except cholesterol and
483
KLINEFELTER’S
TABLE
I
SYNDROME
IN IDENTICAL
Dermatoglyphic
TWINS-NICOLIS
Analysis
TABLE II
Finger and Palm Patterns 123
Hand
4
ET AL
5
S.L. A.T.
.
Is
I(
Hp
Total Finger Ridge Count -
Patient H.B. R L
www w L”
w w
w
w w
0 0
t’ t’
L‘j 0
0 0
0 0
Ld 0
0 L”
0 0
151
Patient D.B. R L
L” w
w w
w w
w w
w L”
0 0
t’ t’
._.
158
NOTE: R = right: L = left. W = whorl; L, = ulnar loop; Ld = distal loop; S.L. = simian line; A.T. = axial triradius; II = third interdigital Hp = hypothenar
TABLE III
pattern; pattern;
I( = fourth 0 = absent.
pattern;
of
Cortisol Patient
vena
cava
4.4
Patient
Left adrenal
475.0
* Radioimmunoassay:
courtesy Hospital,
Columbia-Presbyterian
dione
Estradiol* --
0.119 0.167 1.065
0.00075 0.00287 0.00148
0.157 0.194
0.00130 0.00368
4.706 .-
0.00176 .-
D.B.
23.8 19.1
vein .-.
terone
0.047 0.623 0.066
114.0
Inferior vena cava Left spermatic vein
Estrone and
H.B.
7.7
Left spermatic vein Left adrenal vein
Testos-
Androstene-
0.056 0.947 0.118
of Dr. lnga Dyzenfurth, New York, N.Y.
triglyceride levels* (Table II). The results of the endocrinologic studies are shown in Tables II and III. Chest films, skeletal survey and excretory urogram were normal as was the electrocardiogram. l.Q.+ was 93 for H.B. and 100 for D.B.+ In both patients testicular biopsy specimens showed advanced changes characteristic of adult patients with chromatin-positive Klinefelter’s syndrome. The seminiferous tubules were totally obliterated and hyalinized. They were often difficult to recognize and contained no cellular elements. The Leydig cells were diffusely hyperplastic with occasional adenoma-like clumping (Figures 2 and 3). The H.B.
breast
showed
specimen
ductal
removed
proliferation
at
mastectomy
with multilayered
from
epi-
* The increase in serum lipids resulted from increased levels of both low density lipoproteins (LDLP-TC; H.B. = 220 mg per cent; D.B. = 224 mg per cent) and very low density lipoproteins (VLDLP-TC; H.B. = 55.8 mg per cent; D.B. = 87.6 mg per cent). t Wechsler adult intelligence scale.
484
Studies
Results Patient H.B.
Determination Serum Total
cholesterol
(mg
Triglycerides (mg %) Protein-bound iodine T, resin uptake index Plasma (Irg %) Cortisol (391 Testosterone
%) (pg %)
7.7 0.068
sulfate
(41)
fig/24
hr) [43]
Ejaculate Volume (ml.) Spermatozoa Thyroid
D.B.
372 294 4.7 1.06 10.0 0.039 0.157
sulfate
Urine 17-hydroxycorticoids (mg/24 hr) 17-ketosteroids (mg/24 hr) Total gonadotropin (mouse units/ 24 hr) Testosterone glucuronide &g/24 (EI/E2/EJ
Patient
0.082
1411
hr) (421 Estrogens
345 331 5.1 0.99
1401
Androstenedione [40] Dehydroepiandrosterone Androsterone
Hormonal Steroids in the Inferior Vena Cava and in the Adrenal and Spermatic Veins -Plasma Concentration (pg %)
Simultaneous Catheterization
Inferior
interdigital
Results of Laboratory
65.9
81.9
12.9
39.4
6.1 9.0
7.1 9.4
>20
<50
>20
<50
43.9
35.0
81-14
10/o/3
0.7 None
1.0 None
function
lJ1l uptake (%/24 hr) Thyroidal clearance (ml/min)
17 19
... . *.
lining of the ducts (Figure 4). The ducts were surrounded by the characteristic cuffs of loose connective tissue which are commonly seen in cases of gynecomastia of relatively recent onset [13]. The interlobular stroma was made up by fibroblastic rather vascular connective tissue. Leukocyte typing for the HL-A3, HL-A9, R* and Te58 antigens gave an A match. In addition, the patients had the following blood groups in common: Al+, A+, B--, thelial
D+, CS, E-, ct, e+, CW-, Ps, K-, kf, K;-, K”+, M-, N+, S-, s+, Lua-, Fy”+, Jka+. (Dr. D. M. Fotiho, The New York Blood Center.) CYTOGENETIC
STUDIES
The buccal smears of both patients showed 27 per cent of nuclei containing one sex chromatin body of normal size. Their oral mucosa cells were stained with quinacrine mustard as described by Caspersson et al. [14] and by Pearson et al. [15]. In over 200 nuclei examined, no fluorescent body was detected. Seven per cent of the Leydig cells in the testicular biopsy specimen of H.B. and 11 per cent of the Leydig cells of D.B. were chromatin-positive. Chromosome analyses were performed on cultures of peripheral leukocytes, skin and testicular fibro-
The American
Journal of Medicine
KLINEFELTER’S
Figure 2.
Testicular
bio,psy specimen
from
H.6.
SYNDROME
Testicular
Figure 3.
IN IDENTICAL
biopsy
Chromosome
TABLE IV
TWINS -
specimen
Analysis
NICOLIS
ET AL
from D.B.
of Tissue Cultures
ChromosomeCount 45
Culture
46
47
20 20 20
0 0 0
0
20
0
0
20
0
Patient
Patient Blood Skin
Figure 4.
Breast
biopsy specimen
from H.B.
blasts. These studies revealed a 46,Xx constitution in all tissues studied (Table IV). The metaphases of these cultures were stained with quinacrine dihydrochloride [15]. No brightly fluorescent Y chromosome was identified. In addition there was no abnormally brightly fluorescent region on any other chromosome which could be interpreted as a translocation of the distal portion of the long arm of the Y. The karyotype of H.B. stained with quinacrine dihydrochloride is shown in Figure 5. The metaphases of both patients were also studied by the differential staining technic of Arrighi and Hsu [16]. With this technic, the deoxyribonucleic acid (DNA) is first denatured with sodium hydroxide and then partially renatured with sodium citrate buffer. The basis of the differential staining is that the repetitive DNA which has renatured most rapidly combines better with the stain. The Y chromosome is readily identifiable by the dense staining of the distal two-thirds of the long arm. The other chromosomes also show characteristic
Volume 52, April
1972
H.B.
0 0 0
Blood Skin Testis
D.B.
centromeric staining [17]. By this technic no densely stained segment of the Y chromosome was detected. The karyotype of D.B. stained with this technic is shown in Figure 6.
COMMENTS Nelson patients tures
and with may
Heller
[18]
Klinefelter’s vary
first
recognized
syndrome
considerably,
that
clinical
especially
in fea-
those
reflect Leydig cell function. Thus, the disorder encompasses a spectrum that ranges from subjects who are severely eunuchoidal to those who are fully virilized. With the advent of chromosomal analysis, however, it has become apparent that some of the patients with karyotypes that differ from the classic 47,XXY form of the disorder may have distinguishing clinical features. For example, patients with the 48,XXXY and the 48,XXYY karyotypes are characterized by the consistent presence of mental deficiency. Those with the 49,XXXXY karyotype, in addition to being mentally deficient, often show short stature, small genitalia, undescended testes and skeletal malformawhich
485
KLINEFELTER’S
SYNDROME
IN IDENTICAL
TWINS -
NICOLIS
ET AL.
tions. Mosaics with a normal 46,XY testicular cell line may have virtually normal gonadal function [19-211. It can be seen from Table V that phenotypic males with the 46,Xx karyotype have the essential features of Klinefelter’s syndrome. The testes were invariably small and all but one patient (Case 13) had azoospermia. Exploratory laparotomy was carried out in two patients and disclosed normal Wolffian structures and no abnormal Miillerian remnants. In most of the other cases the epididymis, the vasa deferentia, the prostate and the seminal vesicles were described as being clearly normal at palpation. In all cases the urethra had a normal meatus. Two patients had unilaterally undescended testes, one was considered
to be mentally deficient, and no skeletal anomalies were present. The mean maternal age (28.3 years) was not significantly different (p >O.OS) than that found by Friiland [20] for forty-one Danish patients (32.3 years) and by Court Brown et al. [3] for eighty-three Scottish patients (32.5 years) with chromatin-positive Klinefelter’s syndrome. A majority of the investigators who have reported previous cases [1,2,4-6,9,1 l] have remarked that their patients with the 46,Xx karyotype differed in some respects from those with the classic form of the disorder. In most cases the habitus was typically male. Facial hair was normal. There was no gynecomastia. The urinary gonadotropins were normal, and the testicular histology showed relatively little tubular damage. The pub-
Quinacrine dihydrochloride Figure 5. stain of karyoiype from H.B. (top) compared to normal male (bottom). Skin.
486
The American
Journal of Medicine
KLINEFELTER’S
lished males
degree present
photographs support the impression that with the 46,Xx karyotype tend to be better
-
7
13 -
-
14 -
lo
%Q
I9
- 20
8
I5
-
9
-
II
-
12
I6
I7
-
I8
ifii;u
b’
t0
21
IN IDENTICAL
of Leydig cell in all patients.
TWINS -
hyperplasia,
NICOLIS
however,
ET AL.
was
Azoospermia was present in all but one patient (Case 13) who had spermatozoa in his urine. His testicular histology and karyotype were not studied, however, and it seems possible that he was a mosaic with a normal 46,XY cell line in the testis like the patients described by Lindsten et al. [6] and by Brb;gger and Aagenaes [23]. Also of note is that urinary gonadotropin levels were clearly elevated in only three patients [6,8,9], questionably in two [1,13] and normal in seven ([2,7,10,11,12] and our two). In classic Klinefelter’s syndrome, urinary gonadotropin levels are almost invariably elevated as was the case, for example, in 94 per cent of the cases reported by
virilized than those with the 46,XXY karyotype. However, the already mentioned variability of this feature in Klinefelter’s syndrome, together with the small number of patients described to date, make it difficult to separate the males with the 46,Xx karyotype into a distinct variant form. The testicular histopathology of phenotypic males with the 46,Xx karyotype was considered typical of chromatin-positive Klinefelter’s syndrome in eight cases ([3,6,7,9,11,14] and our two). In the six other cases [1,2,5,8,10,12] in which data are available the tubular damage was distinctly less severe, and the histologic picture was similar to that seen in patients with germinal cell aplasia [22]. Some
-6
SYNDROME
-.
-22
Y
-6-7-8-9-1O;II-I2
l3-
19
l4-
I! - 20
Volume 52, April 1972
15
-16
21
I7
-22
-
I8 II Y
Figure
6. Differential DNA stain of karyotype from D.B. (top) compared to normal male (bottom). Peripheral blood.
487
KLINEFELTER’S
TABLE V
SYNDROME
Clinical
IN IDENTICAL
and Laboratory
Findings
De La Chapelle et al. 1964 [l]
Data
TWINS-
NICOLIS
ET AL.
in 46, XX Males
Therkelsen 1964 [2]
Court Brown et al. 1964 [3j
De La Chapelle et al. 1411965
Strauch et al. 1965 [5j
Lindsten et al. 1966 [S]
Patients’ &
3:
(yr)
1:
2:
Age
Maternal Paternal
Mr;;rtments
25 0
26 31
(cm) 172 91.5 174
Lo&r segment Span Hair Facial ;;;;ry
Absent
N
2.5, 1.0 cm 0
Ejaculate
Low Normal 14
Intelligence Puberty (age) 17-ketosteroids
9.8-6.3
(mg/24 hr) W5/EI (424 hr)
aH-thymidine autoradiography Testicular histology
0 Slightly hypoplastic 3.0 cm
4cm
Testes
Chromosomal. analysis
Sparse N N -
! -
Gynecomastia Prostate Penis
Gonadotropins [MU/24 hr) Sex chromatinpositive
167 0 0
167
154
1::
1::
N
N
Absent
scaNnty
I! +
scaNnty -
+ 0 N 2.0 cm
Small
Small
Subnormal Moderate hypoplasia Very small
-
0
0
0
N 14
0 0 0
0 0 0
N N 6.5
7.0-8.9 (20-50 MU; N)
0
0
0
0
>40;
69-72 (N)
0
0
0
>lOO
Buccal mucosa leukocytes
Buccal mucosa skin, testis
Buccal mucosa
Buccal mucosa leukocytes Blood, skin
0.65/0.0/3.1
Blood, bone marrow, peritoneum, skin, fascia, testis Leukocytes
Blood, skin, testis
1
Blood, skin
-
-
Tubular hyalinization with some Sertoli cells: ;t-iig
Mild peritubular fibrosis; Sertoli cells and spermatogonia in tubules; Leydig cell hyperplasia
No hyalinization; mild peritubular fibrosis; Sertoli cells in tubules; Leydig cell hyperplasia
Athletic; normal internal male structures at laparotomy
Normal male habitus; Sertoli cells chromatin negative
...
= absent;
no information;
N = normal.
0
Buccal mucosa
Buccal mucosa skin, testis
N Subnormal Prepuberal 0
NOTE: + = present:
488
-
0 =
...
+I SF
N Prepuberal 5.4-7.7 2.6/0.7/1.9 >13 <53 Buccal mucosa skin, testis
8.# (< >s But n S tc
Blood, skin, testis
+
Blood, skin, testls
Blood, skin, testis
Blo
Skin
Skin, leuko. cytes
Let
Gel
Tubules with slightly thickened walls and Sertoli cells; Leydig cell hyperplasia
Diffuse tubular sclerosis; rare Sertoli II cerrs; Leydig cell hyperplasia
50% tubular sclerosis; 50% tubules with Sertoli II cerrs; Leydig cell hyperplasia
Normal male habitus
“Very masculine and hairy”
Normal male structures at laparotomy: DNA content of sex chromatin equal to normal female; atd angles similar to Turner’s syndrome
present Miscellaneous
1.
The
American Journal
of
Medlclne
Sl
C
C
s t S
KLINEFELTER’S
t et al. 6 171
DeGrouchyet al. 1966]8]
4; 39 40 67 6: arse anty N -
36
34
23 0
:
18 0
157 84 0
170 92 0
Absent N N -
N
8cm
?rries
Small
N N i.8
0
:
N N
N N
1.5 cm
2.0 cm; R. undescended 0
Deficient 0 5.3-11.2
I.Q. 96 14 7.2
16
x 0 + 0 0 R. undescended
0
0
0
0
>6
0
0
Buccal m ucosa
skin, s
Blood, testis
Blood, testis
Blood, skin, testis
Blood, skin
Blood, skin
:ytes
-
-
Leukocytes
Leukocytes
Thickening of basement membrane; Sertoli cells, few spermatogonia, spermatocytes; Leydig cell hyperplasia
Tubules hyalinized; Leydig cell hyperplasia
Tubules 70% sclerosed; 30% with Sertoli cells: moderate Leydig cell hyperplasia
0
Feminine fat distribution
Sertoli cells chromatin negative; atd angles and total ridge count similar to Turner’s syndrome; quinacrine stain of bone marrow and blood cultures
‘Sperm in urine,” “patent ductus arteriosus,” “quite masculine”
..
Volume
52,
April
1972
lnguinal
0 0 0
0
Buccal mucosa
?S :ult to gnize; lig ceil xplasia
: 0 0 0 0
0
Buccal mucosa, Leydig ceils
osa
17
30 32
x
0 0 4.0
Buccal mucosa
I
13.2
ET AC.
49
30 32
0
Buccal mucosa
>5 125
15 7 mo
a
4.0/0.0/7.3
35
NICOLIS
0 8 0
5 Ag (follic. ulin) <50 >25
.5/1.7
TWINS-
Nicolis et al. 1971
Chin
Small N
+ (azoospermia)
IDENTICAL
George,Polani 1970 1121
165
! -
0
IN
:
!
Almonds
1.0. 91 Prepuberal 3.0
24
I!! N
0
bosper-
163
Powers et al. 1970 [ll]
i Feminine
0
IUVl
Boczkowsky et al. 1969 ]9,10]
SYNDROME
0
“Klinefefterlike”
N Absent Scanty + Small 6cm
N Absent Scanty
1.0
1.0 cm
cm
0.5 cc (azoospermia) I.Q. 93 14 9.0 8/-/4
1.0 cc(azoospermia) I.Q. 100 14 9.4 10/O. G/3
>20 <50
>20 <50
Buccal mucosa
Buccal mucosa, Leydig cells
Blood, skin
Blood, skin, testis
Buccal mucosa, Leydig cells Blood, skin
0
N hyalinization; Leydig cell hyperplasia
Quinacrine stain, blood and skin culture
+ Small 6cm
Quinacrine stain, blood and skin culture
Complete tubular hy aiinization; Leydig cell hyperplasia
Quinacrine and Quinacrine differential and differDNA stains; ential DNA buccal mucosa; stains: skin leukobuccal cytes and mucosa; testis cultures skin and leukocytes cultures
489
KLINEFELTER’S
SYNDROME
IN IDENTICAL
TWINS -
NICOLIS
ET AL.
Paulsen et al. [24] and in 78 per cent of those reported by Becker et al. [25]. Since plasma testosterone has not been previously measured in male subjects with the 46,Xx karyotype, no objective proof exists of the clinical impression that their Leydig cell function may be better maintained than in most patients with classic Klinefelter’s syndrome. In our two patients plasma testosterone was low and considerably lower than the mean found by Paulsen et al. [24] in twenty patients with the chromatin-positive Klinefelter’s syndrome (mean 0.280 pg per cent; range 0.04 to 0.88 pg per cent). Although the plasma testosterone level in our patients was in the female range it appeared to derive mostly from testicular secretion rather than the peripheral conversion of other androgens as is the case in the normal female [26]. This was shown by a gradient in the concentration of testosterone between the spermatic vein and the general circulation (Table Ill) similar to that found by us [27] in normal men. Several possibilities could explain the development of male gonads in the presence of the 46,Xx karyotype: (1) mosaicism with an undetected XXY cell line; (2) loss of a Y chromosome from an original XXY zygote during early embryonic life; (3) undetected Y translocation, and (4) X-Y interchange during paternal meiosis. The last possibility, suggested by Ferguson-Smith [28], is supported by the observation that two of the males with the 46,Xx karyotype [1,4] were Xg a- as were their mothers, whereas their fathers were Xg a+. The failure, of males with XX sex chromosomes to inherit any Xg a allele from the Xg a+ fathers suggests an X-Y interchange during paternal meiosis. This interchange would result in the exchange of male detemining loci from the Y chromosome for the region containing the Xg a gene in the short arm of the X chromosome. The possibility of an original XXY zygote with early loss of a Y chromosome is also compatible with the Xg data since both X chromosomes of males with XX sex chromosomes could have derived from the ,mother by meiotic nondisjunction. However, this requires three abnormal events: (1) the production of an XXY zygote, (2) the loss of a Y during early embryonic development by anaphase lag and (3) the loss of the XXY line after the second event. From the philosophic point of economy of nature this sequence is less likely than the single event of X-Y interchange. The absence of a fluorescent Y in interphase and metaphase cells of our two patients as well as in three previously reported males
490
with XX chromosomes [10,12,29] does prove Ferguson-Smith’s hypothesis. It cently been shown [30] that the specific
not dishas restaining involves the distal heterochromatic portion of the long arm of the Y chromosome. At the same time it seems clear that the male determining genes are located on the short arm of the Y chromosome [31,32] and that this is the portion which associates with the X chromosome during the first meiotic metaphase [33,34]. The short arm of the Y chromosome does not carry a characteristic fluorescent banding pattern nor specific staining properties by the differential staining technic, Therefore, any translocation or interchange involving the short arm of the Y chromosome cannot be identified by the present methods. An increased frequency of twin births in the families of patients with Klinefelter’s syndrome was first noted by Hdfnagel and Benirschke [35] and later confirmed by Nielsen [36]. The latter investigator analyzing the families of twenty patients with the XXY karyotype and of five patients with the XV/XXV karyotype found an incidence of multiple births of 5.59 per cent or 3.4 times the expected. The twin births associated with the Klinefelter’s syndrome may involve relatives, siblings or the patients themselves. In the latter case the twin may be a normal fraternal or an identical twin with the same chromosomal abnormality. The data in the eight cases of identical twins with the chromatin-positive Klinefelter’s syndrome published before 1968 have been reviewed by Vague et al. [37], and a further case was described by Klotz et al. [38] in 1969. Since advanced maternal age is known to be linked with an increased incidence of both the Klinefelter’s syndrome and multiple births, it was initially thought that this explained the association of two disorders. However, Nielsen [36] pointed out that the incidence of twin births in families of patients with Klinefelter’s syndrome is greater than expected even if correction is made for maternal age and that a different mechanism must be operative. Although the nature of this mechanism is not clear at present the high frequency of twins in the sibships with Klinefelter’s as well as Turner’s syndrome indicates a relation between the causes of sex chromosome nondisjunction and of multiple births [36]. ACKNOWLEDGMENT We are grateful to Miss Dora Brenholz, Mrs. Erlinda Conception, Miss Enid Kutinsky and Mrs. Gloria Vanderburg for technical assistance.
The ‘American Journal of Madiclne
KLINEFELTER’S
SYNDROME
IN IDENTICAL
TWINS-
NICOLIS
ET AL.
REFERENCES 1.
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