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True hermaphroditism and chimerism
True hermaphroditism and chimerism A case report
K. BENIRSCHKE F. XAFTOLIN R. R . GITTES G.KHUDR S. S. C . YEN
F . H. ALLEN, JR. JR . La Jolla, California, and New York, New York A case of true hermaphroditism is reported with feminine habitus, ovotestis, and XXI XY cell admixture. Whole body chimerism could be proved to exist by the disco very of different blood groups and PGM types. This is the eleventh case of discovery "whole-body chimerism" reported, a condition thought to be more common than recognized. Diagnosis of the existence of two cell lines was enhanced by the use of the quinacrine mustard fluorescent technique. This technique is advocated for future study of similar cases, with touch preparations to obviate the necessary selection of cells occurring in tissue culture.
When assessment of the human chromosomal complement became possible, it also became feasible to examine the hypothesis that more than one line of cells might be present in such patients. Polanil records 108 patients on whom chromosome analysis was undertaken, to which at least 11 others that were reported since his review may be added. s3 -- 9 In only a minority of these patients was more than one line of cells detected. Polani'sl findings in 108 cases were 59-46XX, 21-46 XV, and 28-chimeras and mosaics2 without Y and 26 with Y. When the subsequently recorded cases are added, the cytogenetic findings in true hennaphrodites hermaphrodites are as presented in Table I. 1. I t is the purpose of this report to record the clinical and cytologic studies of a new true hermaphrodite who was proved to be a whole-body chimera. The patient was initially considered to be monoclonal 46XX, but fluorescent microscopic studies for the demonstration of Y chromosomes allowed detailed scrutiny of multiple tissues and the
T RUE hermaphroditism is defined as a condition in which both ovary and testis, or an ovotestis, are present. The development of MUllerian and Wolffian ducts is most frequently feminine, with some degree of virilization; however, the spectrum is highly variable. In a recent review Polani 1 records 339 reported cases in man and we have cited the documented cases recorded in the veterinary literature. 2 Thus, the condition is not uncommon and has posed important questions not only in the management of individual patients but also with respect to the etiology and pathogenesis of this intersex state. From the Departments of Obstetrics and GynecoloKY, Gynecol08Y, Pathology, and Surgery, University of California, San Diego, and The New York Blood Center. Supported by a grant (RF70029) from The Ro&kefeller Foundation Foundation,, by Grants HE08630 and HE090ll from the NHLI, NHLl, and a grant from the Fay-Hunter Estates. Presented at the Thirty-eighth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Rancho La Costa, California, Oct. Costa. Crdifornia, Oct . 5-10, 1971.
449
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Table I. Cytogenetic findings m tflle hermaphrodites"
:l-:'
61- ·· 46 XX :!3-'\·6 XY '1:i-mosaics and chimeras 119
Total
11-4:iX/46XY Mosaics 10-46XX/ 46XY 6-46XX/47XXY and chimeras 6--Others :!.
:15
With Y Without Y
Total
detection of an XY clone. The frequency of this cell line in different tissues was found to be quite variable and it is suggested that perhaps other patients thought to be monoclonal XX or XY may be found to be chimeras when more detailed study, employing this technique, is undertaken. Patient Ophelia S. (U-411417), a 20-year-old, 113 pound, 5 foot tall, Mexican woman was first admitted to University Hospital July 21, 1967, for evaluation of genital and endocrine abnormalities discovered during a preimmigration physical examination. The patient had been raised as a female since birth, although a large clitoris had been noted after the delivery and caused extreme embarrassment to the family and more recently to the patient. The pregnancy had been unremarkable, with a spontaneous birth at home followed by delivery of the placenta at a local hospital. Although the genital abnormality was noted since birth, no mention was made of abnormalities of the placenta, nor was there any apparent evidence of a second fetus. There was no consanguinity and no medications were taken in relation to this pregnancy. There is no history of twinning in the family and the general family history was unremarkable. Development as a child had been "normal," although she was always smaller than her seven brothers and one sister were at the same age. The entire family is of short stature. By the age of 15 years the patient had begun to have regular monthly menstrual periods lasting 3 to 5 days. Despite the growth of axillary and pubic hair she had not yet had any breast development. A small amount of excess facial and body hair had been noted. Her lack of interest in boys was at least in part due to a frankly admitted embarrassment
Fig. 1. ~ark cd clitoral hypertrophy and relative vaginal introital stenosis prior to plastic surgery. over the enlarged clitoris and her masculine features. Miss S. had otherwise enjoyed good health, as had her parents and siblings. Examination revealed a pleasant young woman with definite masculine features. Except as noted below she was completely normal with a generally muscular appearance and a masculine pattern of hair growth (sparse facial and breast hair, slight temporal recession, and subumbilicalpubic hairline). There were no acne, striae, or abnormal fat pads present. There was no "zebra striping" of skin or heterochromasia of the irides. The breasts were small with a minimal amount of glandular tissue palpable. The external genitals were mixed in character. The pubic hair was sparse, the mons was normal. The c:litoris was more than 1 cm. in diameter and 3 cm. in length, forming a phallus with a thirddegree hypospadias (chordee and a slitlike groove in the glans) (Fig. 1). Just posterior to thc urethral orifice was a small vaginal opening. Th!' rugous labia were fused in the midline. Rectal examination was unremarkable, with only a walnut-sized structure felt in the midline of the pelvis. This was described as feeling "like a small prostate" by the examining urologist. Endoscopy revealed a normal urethra and bladder with
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Fig. 2. Fig. 2. Right Right ovotestis. ovotestis. At At right right is is the the spongy, spongy, at left left the the large large ovarian ovarian brown testicular brown testicular tissue, tissue, at sevportion with portion with hemorrhagic hemorrhagic corpus corpus luteum luteum and and several cysts. eral follicle follicle cysts. bilateral single bilateral single ureteral ureteral orifices. orifices. The The vagina vagina led led to aa small to small cervix, cervix, and and biopsy biopsy demonstrated demonstrated ininactive and intact intact endocervical endocervical active endometrium endometrium and glands. Laboratory Laboratory studies studies were were all all normal and glands. normal and included complete included complete blood blood count, count, urine urine analysis, analysis, BUN, BUN, postprandial postprandial blood blood glucose, glucose, serum serum bicarbicarbonate, bonate, chloride, chloride, sodium, sodium, potassium, potassium, and and phosphorus, phosphorus, as as well well as as 24 24 hour hour urinary urinary ketoketo- and and hydroxysteroids and pregnanetriol. pregnanetriol. Korma! Korma! chest chest hydroxysteroids and x-ray x-ray and and intravenous intravenous urograms urograms were were obtained. obtained. The The bony bony pelvis pelvis was was gynecoid. gynecoid. Twelve Twelve to to 18 18 per cent per cent of of cells cells in in aa buccal buccal smear smear were were found found to contain to contain aa chromatin chromatin body. body. The patient The patient was was readmitted readmitted on on Oct. Oct. 18, 18, 1967, 1967, for for exploratory exploratory laparotomy laparotomy and and plastic plastic repair repair of of the external the external genitals. genitals. A A normal normal tube tube and and ovary ovary were found were found on on the the left left side. side. The The uterus uterus was was normal. Grossly, no normal. Grossly, no tube tube was was recognized recognized on on the the The right right gonad gonad was was an an ovotestis ovotestis right right side. side. The (Fig. 2) 2) which which was removed with with its its pedicle. pedicle. (Fig. was removed The The fused fused labia labia were were separated separated by by aa standard standard midline midline incision, incision, and and submucosal submucosal burial burial of of the the phallus was was performed. performed. Microscopic Microscopic examination examination phallus confirmed the the presence presence of of immature immature testicular testicular confirmed tubules with with only only Sertoli Sertoli cells cells present present (Fig. (Fig. 3). tubules 3). No germinal No germinal cells cells were were seen, seen, while while interstitial interstitial cells cells were were plentiful. plentiful. The The ovarian ovarian portion portion of of the the right right gonad gonad (Fig. (Fig. 4) 4) contained contained maturing maturing GraafGraafian ian follicles follicles and and aa corpus corpus luteum. Iuteum. Fallopian Fallopian tube tube and and aa parovarian parovarian cyst cyst were were found found in in the the tissue adjacent tissue adjacent to to the the ovotestis. ovotestis. She She was was disdischarged charged and and instructed instructed to to use use vaginal vaginal stilbestrol stilbestrol cream. cream. On Sept. Sept. 3, 3, 1969, 1969, the the patient patient was was readmitted readmitted On
True hermaphroditism True hermaphroditism and and chimerism chimerism 451 451
Fig. Fig. 3. 3. Microscopic Microscopic appearance appearance of of testicular testicular porportion of tion of right right ovotestis. ovotestis. Cluster Cluster of of Leydig Leydig cells cells proteinaceous above; tubules tubules contain contain eosinophilic eosinophilic proteinaceous above; fluid ; absence absence of of germ germ cells. cells. (Hematoxylin fluid; (Hematoxylin and and xI60.) eosin. eosin. x160.)
Fig. 4. Fig. 4. Appearance Appearance of of ovarian ovarian portion portion of of ovotestis ovotestis with with numerous numerous primordial primordial ova. ova. Elsewhere Elsewhere aa nornormal corpus corpus luteum luteum was was present. present. (Hematoxylin (Hematoxylin and and mal eosin. x160.) eosin. xI60.) for the midline for vaginal vaginal reconstruction: reconstruction: the midline vaginal vaginal incision had had stenosed stenosed to to aa point point and and the the large large incision glans recessed phallus glans of of the the recessed phallus was was insensitive insensitive and and unsightly. Phallectomy unsightly. Phallectomy and and aa V-flap V-flap perineal perineal skin skin vaginoplasty gave gave an an excellent excellent result. result. Cyclic Cyclic vaginoplasty diethylstilbestrol (1 diethylstilbestrol (1 mg. mg. daily daily for for 25 25 days days and and resting for resting for 55 days) days) was was administered administered in in an an atattcmpt to achieve breast development. Despite the estrogen therapy therapy her estrogen her periods periods continued continued regularly regularly each each month. month. They They were were not not coincident coincident with with the the The patient patient reported reported aa withdrawal of of estrogen. estrogen. The withdrawal feeling of of increased increased well-being well-being and and femininity femininity on on feeling this this regimen. regimen. On Nov. Nov. 9, 9, 1970, On 1970, the the patient patient was was readmitted readmitted for left left gonadal gonadal biopsy biopsy and and augmentation augmentation mammamfor moplasty. Last Last menstrual menstrual period period was was Nov. Nov. 2-7, 2-7, moplasty.
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Table II. Percentage of cells having V-fluorescent spot in interphase and metaphase nuclei of various tissues. Hundreds of cells were scored in each case; however, the percentage does not faithfully score the frequency of XY cells, rather, it represents an underestimate. Between 10 and 20 per cent of cells taken from normal males, in our experience, do not show an F spot
FSH
14
Day of Cycle Fig. 5. Serum LH and FSH in Patient O. S. Despite the discontinuance of daily diethylstilbestrol (1 mg.) there was no withdrawal bleeding. There was no evidence of corpus luteum formation in the ovarian biopsy (Qu. Bx.). LH levels were high for any time of the normal cycle except the midcycle surge. 1970. Gonadal and breast biopsies revealed normal ovarian and breast tissues, respectively. Serum LH levels were high and FSH level normal while the patient was taking stilbestrol 1.0 mg. daily (samples drawn on Days 7 and 8 of cycle) .10 Discontinuation of the therapy was followed by a decrease of LH and an increase of FSH over the succeeding week (Fig. 5 ) . Since discharge the patient has done well.
Cytogenetic studies A lymphocyte culture (3 karyotypes) undertaken in 1967 was reported to be 46,XX. Re-examination of this culture in 1971 disclosed 46XY cells. New cytogenetic studies were carried out in 1970 and 1971 on several tisliues including peripheral blood, skin, ovary, buccal smears, and hair follicles. Unfortunately, the ovotestis was fixed in formalin and no chromosomal studies could be done on it. For adequate identification of the Y chromosome, the quinacrine fluorescent technique was used as described elsewhere. l l The buccal smears revealed 14 per cent Barr bodies but repeatedly showed the complete absence of the V-fluorescent body in interphase nuclei. Several peripheral leukocyte cultures were performed. Screening the cultures with the fluorescent method was very
Y fluorescence in Y flu orescence in interphase nuclei metaphase spread
Buccal smear Hair follicles Leukocyte culture Ovary
~egative
18% 15%
3%
12% 1 metaphase spread containing a Y chromosome was found
helpful in determining the percentage of nuclei containing F bodies and ascertaining the metaphase spreads that possessed a Y chromosome. Our findings (Table II) show the presence of an F body in 15 per cent of lymphocyte nuclei and that 12 per cent of the metaphase spreads were 46XY; 88 per cent were 46XX (Figs. 6 through 8). Tissue cultures from the ovary were not really successful but screening of the atabrine stained nuclei resulted in the finding of 3 per cent with one F body. Only one metaphase spread could be karyotyped as 46XY (Fig. 9 ) . Approximately 500 cells and 200 metaphase spreads were screened in the culture from the left ovary. Hair follicles from the scalp of the patient were studied according to the method of Sperling12 and Cervenka, Jacobson, and Gorlin. 13 Eighteen per cent of the cells contained an F body. Control male specimens revealed 75 per cent F bodies when studied in the same manner. Blood group studies were performed on several occasions. The patient is Xg(a-) and, with the exception of the Duffy blood group, no unusual findings were made. Several anti-Fya sera were employed, all giving a similarly weak reaction. Closer scrutiny showed that approximately half of the red blood cells agglutinated with anti-Fya, while
True hermaphroditism and chimerism 453
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the remainder did not. Thus, the assumption is made that an equal admixture of genetically different red blood cells exists, those Fy (a+) and those Fy (a-). These cells were then examined for phosphoglucomutase (PGM) types. The unagglutinated cells, Fy (a-), were found to have the PG M type 2-1, while the agglutinated cells, Fy (a+) were different but their type could not be clearly established. Comment
The case presented exhibits a number of interesting features. Initially a lymphocyte culture was interpreted as 46XX and only after repeated study was a second clone of cells, 46XY, found. The condition was then properly identified as due to whole-body chimerism. Chimerism differs from mosaicism in that more than one clone of cells is present which can be diagnosed as being derived from more than one zygote by their different genetic expression. In mosaic individuals, those having more than one line of cells with differing chromosome constitution (other types of mosaicism exist, viz., the randon inactivation of one of the two X chromosomes in females, "lyonization"), the origin from one zygote is presumed because of failure to find more
than one genotypic expression, e.g., blood groups. Mitotic nondisjunction of chromosomes is usually held responsible for this event. Miss S. was diagnosed as being a chimera because of her two cell lines (XX and XV) and two differing types of red blood cells, Fy (a+) and Fy (a- ), which also differed in PGM type. It is convenient to separate three types of chimerism14: (a) transplacental (e.g., mother to fetus tumor metastases); (b) blood chimerism (among fraternal twins due to transplacental vascular anastomoses; best known from the freemartin condition in cattle; confined to circulating elements); (c) whole body chimerism. The patient clearly falls into the third category and the variability of admixture ratio among different tissues in striking (Table I). Previously, ten other whole body chimeras have been described in man and several are known in other mammals. 2 Eight of the human chimeras had an XX/XY admixture, one patient was a 2nXX/3nXXY chimera and only one patient was a normal female with two populations of XX cells. Commonly these individuals are discovered because of abnormal sexual development; most have been true hermaphrodites. On the other hand, as indicated initially, many true
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hermaphrodites have had only one clone of cells, XX or XV, demonstrated. In most reported cases only lymphocyte culture was used for this chromosomal diagnosis, and critical blood grouping or a search for differing enzyme phenotypes was not undertaken. A pathogenetic mechanism which explains these presumed monoclonal cases is not at hand. Moreover, in an occasional sibship recurrent 46XX true hermaphrodites have been found. ' 5
'fhe mechanism leading to the gonadal picture in true hermaphroditism is unknown. The simplest assumption is that two clones of cells, present at different frequencies, determine the fate of undifferentiated gonads. Thus, an anlage with a predominance of XY cells might develop into a testis, one with mostly XX cells into an ovary. It has not been possible to substantiate this hypothesis completely. Although previous cases 4 • 1G clearly demonstrate that it may re-
True True hermaphroditism hermaphroditism and and chimerism chimerism 455 455
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Fig. 9. Fig. 9. Same Same method method as as Fig. Fig. 8; 8; XY XY metaphase metaphase from from ovary. ovary.
quire repeated quire repeated biopsies biopsies before before an an XY XY clone clone and the the present present case case indiindican be be detected, detected, and can cates the the highly highly variable variable frequency frequency of of such such cates other well well clone throughout throughout the the body, body, other aa clone second studied not revealed revealed aa second studied cases cases have have not One problem problem is is that that many many cell cell types types clone. One clone. in tissue tissue culture culture and and thus thus fail to fail to proliferate proliferate in cannot be cannot be analyzed analyzed for for their their chromosome chromosome constitution; can be be made made constitution; only only inferences inferences can from from Barr Barr body body counts. counts. Moreover, Moreover, karyotypkaryotypis only only conclusive conclusive in in excellent excellent preparapreparaing ing is tions tions and, and, finally, finally, during during growth growth and and developdevelopment as ment as well well as as cell cell culture, culture, some some lines lines of of cells may cells may be be selected selected against, against, even even vanish. vanish. The availability The availability of of the the fluorescent fluorescent techtechthe detection detection of of the the Y Y chromochromonique nique for for the 13 ll 13 some somell -greatly eased greatly eased the the study study of of this this patient. It was was possible possible to to screen screen larger larger popupopupatient. It lations lations of of cells cells and and also also cells cells that that would would not not have have been been cultured cultured (e.g., (e.g., hair hair shaft, shaft, buccal buccal mucosa). mucosa). Figs. Figs. 10 10 and and 11 11 clearly clearly indicate indicate the the advantage advantage of of this this technique technique and and it it is is suggested that suggested that future future cases cases be be studied studied emem-
ploying this ploying this method. method. More More important, important, perperis suggested suggested that that numerous numerous touch touch haps, haps, it it is preparations preparations be be prepared prepared from from tissues tissues reremoved, particularly the the different different portions portions of of moved, particularly ovotestis. Thus ovotestis. Thus it it may may be be possible possible at at aa later later date these tissues date to to assess assess these tissues more more meaningfulmeaningfully. Touch ly. Touch preparations preparations can can subsequently subsequently be be are Papanicolaou Papanicolaou smears smears and and stained stained fixed as fixed as are with atabrine with atabrine for for fluorescence fluorescence and and subsesubseBarr body body examination. examination. Ideally, Ideally, quently for quently for Barr on formaformasimilar studies similar studies could could be be undertaken undertaken on lin fixed lin fixed tissue tissue but but attempts attempts in in this this direction direction so far. far. Furthermore, Furthermore, have been have been unsuccessful unsuccessful so in these in these cases cases greater greater efforts efforts in in blood blood groupgroupand the the search search for for several several protein protein genogenoing and ing types types would would probably probably be be rewarding. rewarding. Whole body chimeras chimeras can can theoretically theoretically Whole body arise by arise by aa variety variety of of mechanisms. mechanisms. Double Double fertilization of fertilization of aa double-nucleated double-nucleated ovum ovum (Fig. 12) 12) is is one one possibility; polyandry, (Fig. possibility; polyandry, polygyny, and fusion fusion of of two two zygotes zygotes are are polygyny, and others. In this others. this respect respect it it is is of of interest interest that that of of 11 such such patients patients one one was was aa twin twin and and in in anan11
456 Benirschke et (;11, 456 Benirschke et QI,
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Fig. Fig. 10. 10. Same Same method method as as Fig. Fig. 8. 8. Two Two adjacent adjacent lymphocyte lymphocy te metaphases metaphases and and interphase interphase nuclei nuclei to demonstrate demonstrate the the ease ease of of applicability an interphase interphase nucleus nucleus with with to applicability of of this this technique. technique. At At left left an "F body" "F body" at at arrow, arrow, indicative indicative of of Y. Y. Beneath Beneath aa metaphase metaphase with with fluorescent fluorescent Y Y in in center. center. At At right aa V-negative right V-negative interphase interphase and and metaphase, metaphase, both both XX. XX.
Clll CIII \
Fig. Fig. 1l. 11. Same Same as as Fig. Fig. 10 10 following following de destaining staining and and restaining restaining with with carbol carbol fuchsin. fuchsin. Division Division of of
XY and XY and XX XX cells cells is is indicated indicated by by line, line, Y Y at at arrow. arrow. Cells Cells were were karyotyped karyotyped to to confirm confirm fluorescent fluorescent stain diagnosis. stain diagnosis.
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other aa history other history of of twinning twinning was was obtained. obtained. that fusion fusion of of early early This might This might suggest suggest that zygotes, as zygotes, as readily readily performed performed experimentally experimentally man in mice, in mice, could could be be the the mechanism mechanism in in man (for review (for review see see ref. ref. 14). 14). Skin Skin mottling, mottling, once once aa typical typical striping, striping, was was found found three three times times and and iris heterochromasia iris heterochromasia twice. twice. These These phenotypic phenotypic are characteristic characteristic features features of of some some expressions are expressions of which which have have male tortoiseshell male tortoiseshell cats, cats, many many of They sugsugalso been also been found found to to be be chimeras. chimeras. 22 They that individuals individuals with with such such unusual unusual feafeagest that gest of tures should tures should be be studied studied for for the the possibility possibility of chimeric populations, chimeric populations, easiest easiest undertaken undertaken at at the outset the outset by by discriminating discriminating blood blood group group At present present whole whole body body chimerism chimerism is is studies. At studies. ascertained almost ascertained almost always always (10 (10 of of 11) 11) bebeof intersexuality, intersexuality, and and XX/XV XX/XV lines lines cause of cause are then are then found found to to coexist. coexist. There There should should be be at least at least as as many, many, if if not not more, more, isosexual isosexual (XX/XX and (XX/XX and XV/XV) XV/XV) chimeras. chimeras. Only Only one one has has been been found, found, aa normal normal woman woman with with two two and XX XX cells. cells. 33 blood blood groups, groups, skin skin mottling mottling and An interesting An interesting finding finding in in the the present present case case is the is the identification identification of of an an XY XY line line (3 (3 per per cent) in cent) in the the normal normal left left ovary ovary (Fig. (Fig. 11). 11). To To our knowledge our knowledge this this is is the the second second time time aa YYcontaining in an an containing line line has has been been observed observed in ovary. Previously, ovary. Previously, Butler Butler and and associates associates 44 in in their third their third case case with with XX/XXV XX/XXV chimerism chimerism in the the ovary ovary 9/XXY 9/XXY and and 26/XX 26/XX cells, cells, found in found in the in the testis testis 7/XXY 7/XXY and and 21/XX 21/XX cells. cells. The The probability of probability of selection selection by by tissue tissue culture culture data insufficient insufficient to to refute refute rendered these rendered these data the hypothesis the hypothesis of of gonadal gonadal determination determination by by XX or XX or XY XY chromosome chromosome predominance predominance of of anlage cells. anlage cells. Nevertheless, Nevertheless, they they should should stimustimulate late more more chromosomal chromosomal inventories inventories by by touch touch in the the future. future. preparations preparations in The presence The presence of of aa normally normally functioning functioning in true true hermaphhermaphfemale neuroendocrine female neuroendocrine axis axis in roditism is roditism is attested attested to to by by the the finding finding of of lutea in in the the ovaries ovaries of of some some 25 25 per per corpora lutea corpora cent of cent of these these cases. cases. In In our our case case there there was was not not only evidence only evidence of of feminine feminine development development (psyche, some (psyche, some breast breast tissue, tissue, complete complete MiilMiillerian system, lerian system, regular regular menses menses with with corpus corpus luteum formation luteum formation in in the the ovotestis) ovotestis) but but there there was also was also evidence evidence of of function function of of the the testis testis (masculine facial (masculine facial conformation, conformation, excess excess facial facial and hair, clitoromegaly, hair, clitoromegaly, labial labial scrotalization, scrotalization, and
True hermaphroditism True hermaphroditism and and chimerism chimerism 457 457
Fig. 12. Fig. 12. Portion Portion of of Graafian Graafian follicle follicle from from oophorecoophorectomy of tomy of another another patient. patient. In In the the cumulus cumulus oophorus oophorus is aa maturing is maturing oocyte oocyte with with two two nuclei. nuclei. Potentially Potentially such aa cell such cell may may be be precursor precursor to to chimeric chimeric individindividuals. (Hematoxylin uals. (Hematoxylin and and eosin. eosin. x280. x280. From From Obstet. Obstet. Gynecol. 18: Gynecol. 18: 338, 338, 1961.) 1961.)
labial fusion) labial fusion) .. Not Not enough enough is is known known of of the the efefin humans humans to to elevate elevate fects of fects of hemicastration hemicastration in her gonadotropin her gonadotropin pattern pattern and and the the effect effect of of estrogen therapy estrogen therapy further further complicates complicates the the picture. The picture. The range range of of values values found found is is not not so so in castrates castrates and and high as high as those those encountered encountered in postmenopausal subjects. postmenopausal subjects. The The interesting interesting of regular regular periods periods despite despite and and continuation continuation of independent of independent of cyclic cyclic estrogen estrogen therapy therapy also also requires further requires further study. study. Although Although androgens androgens and have been have been seen seen to to affect affect psychosexual psychosexual and 17 hypothalamic imprintation hypothalamic imprintation in in primates primates17 and and lower species,18 lower species,18 this this effect effect has has never never been been in exogenous exogenous or or endogenous endogenous early early found in found androgen syndromes androgen syndromes in in humans. humans. Our Our patient patient was no was no exception exception to to the the rule. rule. Possibly Possibly the the testis portion testis portion was was abnormal abnormal or or the the amount amount of inducing of inducing substance substance was was insufficient insufficient to to imimprint the print the brain. brain. At At the the local local level level this this dedeapparent ficiency may ficiency may be be reflected reflected by by the the apparent lack of lack of aa Fallopian Fallopian tube tube on on gross gross inspection. inspection. The failure The failure of of the the first first plastic plastic procedure, procedure,
458 Benirschke et 01.
both functional and cosmetic, reinforces our preference of the V-flap vaginoplasty described by Fortunoff, Lattimer, and Edson,lO
Am.
J.
June l:J) 197:: Obs!r!. Gyrlt'col.
and the phallectomy practiced by Jones and Heller.~o
REFERENCES
1. Polani, P. E.: Trans. R. Soc. Lond. S.B 259: 187, 1970. 2. Benirschke, K.: IV International Congress on Human Genetics, Amsterdam, 1971, Excerpta Medica Foundation, in press. 3. Race, R. R., and Sanger, R.: Blood Groups in Man, ed. 5, Philadelphia, 1968, F. A. Davis Company. 4. Butler, L. ]., Snodgrass, G. J. A. I., :France, N. E., Russel, A., and Swain, K. A. ].: Arch. Dis. Child. 44: 666, 1969. 5. Makino, S.: Proc. Sixth World Congr. Ferti!. Steril., 1968; Israel Acad. Sci. Human., Jerusalem, 1970, p. 27 6. Fitzgerald, P. H., Brehaut, L. A., Shannon, F. T., and Angus, H. B.: J. Med. Gen. 7: 383, 1970. 7. Park, I. J., Jones, H. W., and Bias, W. B.: Obstet. Gyneco!. 36: 377, 1970. 8. Kakati, S., Sharma, T., Udupa, K. N., and Chaudhuri, S. P. R.: Ind. J. Med. Res. 59: 104, 1971. 9. Moreno, M. J., and Sanchez, 0.: Acta Cient. Venezolana 22: 14, 1971.
10. Yen, S. S. C., Vela, P., Rankin, J., and Littell, A. S.: J. A. M. A. 211: 1513, 1970. 11. Khudr, G., and Benirschke, K.: AM. J. OBSTET. GY:O
K. BENIRSCHKE F. XAFTOLIN R. R . GITTES G.KHUDR S. S. C . YEN
F . H. ALLEN, JR. JR . La Jolla, California, and New York, New York A case of true hermaphroditism is reported with feminine habitus, ovotestis, and XXI XY cell admixture. Whole body chimerism could be proved to exist by the disco very of different blood groups and PGM types. This is the eleventh case of discovery "whole-body chimerism" reported, a condition thought to be more common than recognized. Diagnosis of the existence of two cell lines was enhanced by the use of the quinacrine mustard fluorescent technique. This technique is advocated for future study of similar cases, with touch preparations to obviate the necessary selection of cells occurring in tissue culture.
When assessment of the human chromosomal complement became possible, it also became feasible to examine the hypothesis that more than one line of cells might be present in such patients. Polanil records 108 patients on whom chromosome analysis was undertaken, to which at least 11 others that were reported since his review may be added. s3 -- 9 In only a minority of these patients was more than one line of cells detected. Polani'sl findings in 108 cases were 59-46XX, 21-46 XV, and 28-chimeras and mosaics2 without Y and 26 with Y. When the subsequently recorded cases are added, the cytogenetic findings in true hennaphrodites hermaphrodites are as presented in Table I. 1. I t is the purpose of this report to record the clinical and cytologic studies of a new true hermaphrodite who was proved to be a whole-body chimera. The patient was initially considered to be monoclonal 46XX, but fluorescent microscopic studies for the demonstration of Y chromosomes allowed detailed scrutiny of multiple tissues and the
T RUE hermaphroditism is defined as a condition in which both ovary and testis, or an ovotestis, are present. The development of MUllerian and Wolffian ducts is most frequently feminine, with some degree of virilization; however, the spectrum is highly variable. In a recent review Polani 1 records 339 reported cases in man and we have cited the documented cases recorded in the veterinary literature. 2 Thus, the condition is not uncommon and has posed important questions not only in the management of individual patients but also with respect to the etiology and pathogenesis of this intersex state. From the Departments of Obstetrics and GynecoloKY, Gynecol08Y, Pathology, and Surgery, University of California, San Diego, and The New York Blood Center. Supported by a grant (RF70029) from The Ro&kefeller Foundation Foundation,, by Grants HE08630 and HE090ll from the NHLI, NHLl, and a grant from the Fay-Hunter Estates. Presented at the Thirty-eighth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Rancho La Costa, California, Oct. Costa. Crdifornia, Oct . 5-10, 1971.
449
450 Benirschke et al.
June 15 , 1972
·\ Ifl.
J. Ob,I .. t. (;ynecol.
Table I. Cytogenetic findings m tflle hermaphrodites"
:l-:'
61- ·· 46 XX :!3-'\·6 XY '1:i-mosaics and chimeras 119
Total
11-4:iX/46XY Mosaics 10-46XX/ 46XY 6-46XX/47XXY and chimeras 6--Others :!.
:15
With Y Without Y
Total
detection of an XY clone. The frequency of this cell line in different tissues was found to be quite variable and it is suggested that perhaps other patients thought to be monoclonal XX or XY may be found to be chimeras when more detailed study, employing this technique, is undertaken. Patient Ophelia S. (U-411417), a 20-year-old, 113 pound, 5 foot tall, Mexican woman was first admitted to University Hospital July 21, 1967, for evaluation of genital and endocrine abnormalities discovered during a preimmigration physical examination. The patient had been raised as a female since birth, although a large clitoris had been noted after the delivery and caused extreme embarrassment to the family and more recently to the patient. The pregnancy had been unremarkable, with a spontaneous birth at home followed by delivery of the placenta at a local hospital. Although the genital abnormality was noted since birth, no mention was made of abnormalities of the placenta, nor was there any apparent evidence of a second fetus. There was no consanguinity and no medications were taken in relation to this pregnancy. There is no history of twinning in the family and the general family history was unremarkable. Development as a child had been "normal," although she was always smaller than her seven brothers and one sister were at the same age. The entire family is of short stature. By the age of 15 years the patient had begun to have regular monthly menstrual periods lasting 3 to 5 days. Despite the growth of axillary and pubic hair she had not yet had any breast development. A small amount of excess facial and body hair had been noted. Her lack of interest in boys was at least in part due to a frankly admitted embarrassment
Fig. 1. ~ark cd clitoral hypertrophy and relative vaginal introital stenosis prior to plastic surgery. over the enlarged clitoris and her masculine features. Miss S. had otherwise enjoyed good health, as had her parents and siblings. Examination revealed a pleasant young woman with definite masculine features. Except as noted below she was completely normal with a generally muscular appearance and a masculine pattern of hair growth (sparse facial and breast hair, slight temporal recession, and subumbilicalpubic hairline). There were no acne, striae, or abnormal fat pads present. There was no "zebra striping" of skin or heterochromasia of the irides. The breasts were small with a minimal amount of glandular tissue palpable. The external genitals were mixed in character. The pubic hair was sparse, the mons was normal. The c:litoris was more than 1 cm. in diameter and 3 cm. in length, forming a phallus with a thirddegree hypospadias (chordee and a slitlike groove in the glans) (Fig. 1). Just posterior to thc urethral orifice was a small vaginal opening. Th!' rugous labia were fused in the midline. Rectal examination was unremarkable, with only a walnut-sized structure felt in the midline of the pelvis. This was described as feeling "like a small prostate" by the examining urologist. Endoscopy revealed a normal urethra and bladder with
Volume 113 Volume 113 Number 4 4 Number
Fig. 2. Fig. 2. Right Right ovotestis. ovotestis. At At right right is is the the spongy, spongy, at left left the the large large ovarian ovarian brown testicular brown testicular tissue, tissue, at sevportion with portion with hemorrhagic hemorrhagic corpus corpus luteum luteum and and several cysts. eral follicle follicle cysts. bilateral single bilateral single ureteral ureteral orifices. orifices. The The vagina vagina led led to aa small to small cervix, cervix, and and biopsy biopsy demonstrated demonstrated ininactive and intact intact endocervical endocervical active endometrium endometrium and glands. Laboratory Laboratory studies studies were were all all normal and glands. normal and included complete included complete blood blood count, count, urine urine analysis, analysis, BUN, BUN, postprandial postprandial blood blood glucose, glucose, serum serum bicarbicarbonate, bonate, chloride, chloride, sodium, sodium, potassium, potassium, and and phosphorus, phosphorus, as as well well as as 24 24 hour hour urinary urinary ketoketo- and and hydroxysteroids and pregnanetriol. pregnanetriol. Korma! Korma! chest chest hydroxysteroids and x-ray x-ray and and intravenous intravenous urograms urograms were were obtained. obtained. The The bony bony pelvis pelvis was was gynecoid. gynecoid. Twelve Twelve to to 18 18 per cent per cent of of cells cells in in aa buccal buccal smear smear were were found found to contain to contain aa chromatin chromatin body. body. The patient The patient was was readmitted readmitted on on Oct. Oct. 18, 18, 1967, 1967, for for exploratory exploratory laparotomy laparotomy and and plastic plastic repair repair of of the external the external genitals. genitals. A A normal normal tube tube and and ovary ovary were found were found on on the the left left side. side. The The uterus uterus was was normal. Grossly, no normal. Grossly, no tube tube was was recognized recognized on on the the The right right gonad gonad was was an an ovotestis ovotestis right right side. side. The (Fig. 2) 2) which which was removed with with its its pedicle. pedicle. (Fig. was removed The The fused fused labia labia were were separated separated by by aa standard standard midline midline incision, incision, and and submucosal submucosal burial burial of of the the phallus was was performed. performed. Microscopic Microscopic examination examination phallus confirmed the the presence presence of of immature immature testicular testicular confirmed tubules with with only only Sertoli Sertoli cells cells present present (Fig. (Fig. 3). tubules 3). No germinal No germinal cells cells were were seen, seen, while while interstitial interstitial cells cells were were plentiful. plentiful. The The ovarian ovarian portion portion of of the the right right gonad gonad (Fig. (Fig. 4) 4) contained contained maturing maturing GraafGraafian ian follicles follicles and and aa corpus corpus luteum. Iuteum. Fallopian Fallopian tube tube and and aa parovarian parovarian cyst cyst were were found found in in the the tissue adjacent tissue adjacent to to the the ovotestis. ovotestis. She She was was disdischarged charged and and instructed instructed to to use use vaginal vaginal stilbestrol stilbestrol cream. cream. On Sept. Sept. 3, 3, 1969, 1969, the the patient patient was was readmitted readmitted On
True hermaphroditism True hermaphroditism and and chimerism chimerism 451 451
Fig. Fig. 3. 3. Microscopic Microscopic appearance appearance of of testicular testicular porportion of tion of right right ovotestis. ovotestis. Cluster Cluster of of Leydig Leydig cells cells proteinaceous above; tubules tubules contain contain eosinophilic eosinophilic proteinaceous above; fluid ; absence absence of of germ germ cells. cells. (Hematoxylin fluid; (Hematoxylin and and xI60.) eosin. eosin. x160.)
Fig. 4. Fig. 4. Appearance Appearance of of ovarian ovarian portion portion of of ovotestis ovotestis with with numerous numerous primordial primordial ova. ova. Elsewhere Elsewhere aa nornormal corpus corpus luteum luteum was was present. present. (Hematoxylin (Hematoxylin and and mal eosin. x160.) eosin. xI60.) for the midline for vaginal vaginal reconstruction: reconstruction: the midline vaginal vaginal incision had had stenosed stenosed to to aa point point and and the the large large incision glans recessed phallus glans of of the the recessed phallus was was insensitive insensitive and and unsightly. Phallectomy unsightly. Phallectomy and and aa V-flap V-flap perineal perineal skin skin vaginoplasty gave gave an an excellent excellent result. result. Cyclic Cyclic vaginoplasty diethylstilbestrol (1 diethylstilbestrol (1 mg. mg. daily daily for for 25 25 days days and and resting for resting for 55 days) days) was was administered administered in in an an atattcmpt to achieve breast development. Despite the estrogen therapy therapy her estrogen her periods periods continued continued regularly regularly each each month. month. They They were were not not coincident coincident with with the the The patient patient reported reported aa withdrawal of of estrogen. estrogen. The withdrawal feeling of of increased increased well-being well-being and and femininity femininity on on feeling this this regimen. regimen. On Nov. Nov. 9, 9, 1970, On 1970, the the patient patient was was readmitted readmitted for left left gonadal gonadal biopsy biopsy and and augmentation augmentation mammamfor moplasty. Last Last menstrual menstrual period period was was Nov. Nov. 2-7, 2-7, moplasty.
452
Benirschke et al.
June 15. 19i2 ..\111 . J. Of"'lc!. Gy nrcu l.
D.E. S.
50 40 30 20
LH
/>--.-
10
6
8
1A.'o-A.~
10
12
Table II. Percentage of cells having V-fluorescent spot in interphase and metaphase nuclei of various tissues. Hundreds of cells were scored in each case; however, the percentage does not faithfully score the frequency of XY cells, rather, it represents an underestimate. Between 10 and 20 per cent of cells taken from normal males, in our experience, do not show an F spot
FSH
14
Day of Cycle Fig. 5. Serum LH and FSH in Patient O. S. Despite the discontinuance of daily diethylstilbestrol (1 mg.) there was no withdrawal bleeding. There was no evidence of corpus luteum formation in the ovarian biopsy (Qu. Bx.). LH levels were high for any time of the normal cycle except the midcycle surge. 1970. Gonadal and breast biopsies revealed normal ovarian and breast tissues, respectively. Serum LH levels were high and FSH level normal while the patient was taking stilbestrol 1.0 mg. daily (samples drawn on Days 7 and 8 of cycle) .10 Discontinuation of the therapy was followed by a decrease of LH and an increase of FSH over the succeeding week (Fig. 5 ) . Since discharge the patient has done well.
Cytogenetic studies A lymphocyte culture (3 karyotypes) undertaken in 1967 was reported to be 46,XX. Re-examination of this culture in 1971 disclosed 46XY cells. New cytogenetic studies were carried out in 1970 and 1971 on several tisliues including peripheral blood, skin, ovary, buccal smears, and hair follicles. Unfortunately, the ovotestis was fixed in formalin and no chromosomal studies could be done on it. For adequate identification of the Y chromosome, the quinacrine fluorescent technique was used as described elsewhere. l l The buccal smears revealed 14 per cent Barr bodies but repeatedly showed the complete absence of the V-fluorescent body in interphase nuclei. Several peripheral leukocyte cultures were performed. Screening the cultures with the fluorescent method was very
Y fluorescence in Y flu orescence in interphase nuclei metaphase spread
Buccal smear Hair follicles Leukocyte culture Ovary
~egative
18% 15%
3%
12% 1 metaphase spread containing a Y chromosome was found
helpful in determining the percentage of nuclei containing F bodies and ascertaining the metaphase spreads that possessed a Y chromosome. Our findings (Table II) show the presence of an F body in 15 per cent of lymphocyte nuclei and that 12 per cent of the metaphase spreads were 46XY; 88 per cent were 46XX (Figs. 6 through 8). Tissue cultures from the ovary were not really successful but screening of the atabrine stained nuclei resulted in the finding of 3 per cent with one F body. Only one metaphase spread could be karyotyped as 46XY (Fig. 9 ) . Approximately 500 cells and 200 metaphase spreads were screened in the culture from the left ovary. Hair follicles from the scalp of the patient were studied according to the method of Sperling12 and Cervenka, Jacobson, and Gorlin. 13 Eighteen per cent of the cells contained an F body. Control male specimens revealed 75 per cent F bodies when studied in the same manner. Blood group studies were performed on several occasions. The patient is Xg(a-) and, with the exception of the Duffy blood group, no unusual findings were made. Several anti-Fya sera were employed, all giving a similarly weak reaction. Closer scrutiny showed that approximately half of the red blood cells agglutinated with anti-Fya, while
True hermaphroditism and chimerism 453
Volume 113 Number 4
•
•
I
•
,
,
, ,
.
II
•
.
" Fig. 6. Karyotype from lymphocyte culture in 1970 with 46,XY.
the remainder did not. Thus, the assumption is made that an equal admixture of genetically different red blood cells exists, those Fy (a+) and those Fy (a-). These cells were then examined for phosphoglucomutase (PGM) types. The unagglutinated cells, Fy (a-), were found to have the PG M type 2-1, while the agglutinated cells, Fy (a+) were different but their type could not be clearly established. Comment
The case presented exhibits a number of interesting features. Initially a lymphocyte culture was interpreted as 46XX and only after repeated study was a second clone of cells, 46XY, found. The condition was then properly identified as due to whole-body chimerism. Chimerism differs from mosaicism in that more than one clone of cells is present which can be diagnosed as being derived from more than one zygote by their different genetic expression. In mosaic individuals, those having more than one line of cells with differing chromosome constitution (other types of mosaicism exist, viz., the randon inactivation of one of the two X chromosomes in females, "lyonization"), the origin from one zygote is presumed because of failure to find more
than one genotypic expression, e.g., blood groups. Mitotic nondisjunction of chromosomes is usually held responsible for this event. Miss S. was diagnosed as being a chimera because of her two cell lines (XX and XV) and two differing types of red blood cells, Fy (a+) and Fy (a- ), which also differed in PGM type. It is convenient to separate three types of chimerism14: (a) transplacental (e.g., mother to fetus tumor metastases); (b) blood chimerism (among fraternal twins due to transplacental vascular anastomoses; best known from the freemartin condition in cattle; confined to circulating elements); (c) whole body chimerism. The patient clearly falls into the third category and the variability of admixture ratio among different tissues in striking (Table I). Previously, ten other whole body chimeras have been described in man and several are known in other mammals. 2 Eight of the human chimeras had an XX/XY admixture, one patient was a 2nXX/3nXXY chimera and only one patient was a normal female with two populations of XX cells. Commonly these individuals are discovered because of abnormal sexual development; most have been true hermaphrodites. On the other hand, as indicated initially, many true
454
Benirschke et 01.
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Fig. 8. Atabrine-fluorescent microscopic appearance of XY lymphocyte metaphase. The intensely fluorescent long arms of Y (last element) are obvious.
hermaphrodites have had only one clone of cells, XX or XV, demonstrated. In most reported cases only lymphocyte culture was used for this chromosomal diagnosis, and critical blood grouping or a search for differing enzyme phenotypes was not undertaken. A pathogenetic mechanism which explains these presumed monoclonal cases is not at hand. Moreover, in an occasional sibship recurrent 46XX true hermaphrodites have been found. ' 5
'fhe mechanism leading to the gonadal picture in true hermaphroditism is unknown. The simplest assumption is that two clones of cells, present at different frequencies, determine the fate of undifferentiated gonads. Thus, an anlage with a predominance of XY cells might develop into a testis, one with mostly XX cells into an ovary. It has not been possible to substantiate this hypothesis completely. Although previous cases 4 • 1G clearly demonstrate that it may re-
True True hermaphroditism hermaphroditism and and chimerism chimerism 455 455
Volume 113 Volume 113 Number 4
Fig. 9. Fig. 9. Same Same method method as as Fig. Fig. 8; 8; XY XY metaphase metaphase from from ovary. ovary.
quire repeated quire repeated biopsies biopsies before before an an XY XY clone clone and the the present present case case indiindican be be detected, detected, and can cates the the highly highly variable variable frequency frequency of of such such cates other well well clone throughout throughout the the body, body, other aa clone second studied not revealed revealed aa second studied cases cases have have not One problem problem is is that that many many cell cell types types clone. One clone. in tissue tissue culture culture and and thus thus fail to fail to proliferate proliferate in cannot be cannot be analyzed analyzed for for their their chromosome chromosome constitution; can be be made made constitution; only only inferences inferences can from from Barr Barr body body counts. counts. Moreover, Moreover, karyotypkaryotypis only only conclusive conclusive in in excellent excellent preparapreparaing ing is tions tions and, and, finally, finally, during during growth growth and and developdevelopment as ment as well well as as cell cell culture, culture, some some lines lines of of cells may cells may be be selected selected against, against, even even vanish. vanish. The availability The availability of of the the fluorescent fluorescent techtechthe detection detection of of the the Y Y chromochromonique nique for for the 13 ll 13 some somell -greatly eased greatly eased the the study study of of this this patient. It was was possible possible to to screen screen larger larger popupopupatient. It lations lations of of cells cells and and also also cells cells that that would would not not have have been been cultured cultured (e.g., (e.g., hair hair shaft, shaft, buccal buccal mucosa). mucosa). Figs. Figs. 10 10 and and 11 11 clearly clearly indicate indicate the the advantage advantage of of this this technique technique and and it it is is suggested that suggested that future future cases cases be be studied studied emem-
ploying this ploying this method. method. More More important, important, perperis suggested suggested that that numerous numerous touch touch haps, haps, it it is preparations preparations be be prepared prepared from from tissues tissues reremoved, particularly the the different different portions portions of of moved, particularly ovotestis. Thus ovotestis. Thus it it may may be be possible possible at at aa later later date these tissues date to to assess assess these tissues more more meaningfulmeaningfully. Touch ly. Touch preparations preparations can can subsequently subsequently be be are Papanicolaou Papanicolaou smears smears and and stained stained fixed as fixed as are with atabrine with atabrine for for fluorescence fluorescence and and subsesubseBarr body body examination. examination. Ideally, Ideally, quently for quently for Barr on formaformasimilar studies similar studies could could be be undertaken undertaken on lin fixed lin fixed tissue tissue but but attempts attempts in in this this direction direction so far. far. Furthermore, Furthermore, have been have been unsuccessful unsuccessful so in these in these cases cases greater greater efforts efforts in in blood blood groupgroupand the the search search for for several several protein protein genogenoing and ing types types would would probably probably be be rewarding. rewarding. Whole body chimeras chimeras can can theoretically theoretically Whole body arise by arise by aa variety variety of of mechanisms. mechanisms. Double Double fertilization of fertilization of aa double-nucleated double-nucleated ovum ovum (Fig. 12) 12) is is one one possibility; polyandry, (Fig. possibility; polyandry, polygyny, and fusion fusion of of two two zygotes zygotes are are polygyny, and others. In this others. this respect respect it it is is of of interest interest that that of of 11 such such patients patients one one was was aa twin twin and and in in anan11
456 Benirschke et (;11, 456 Benirschke et QI,
June June 15, 19n 1972
.\JIl. .\w .
.f. ,I. Obstot Obst< t.. G Gynccnl. ynccol.
Fig. Fig. 10. 10. Same Same method method as as Fig. Fig. 8. 8. Two Two adjacent adjacent lymphocyte lymphocy te metaphases metaphases and and interphase interphase nuclei nuclei to demonstrate demonstrate the the ease ease of of applicability an interphase interphase nucleus nucleus with with to applicability of of this this technique. technique. At At left left an "F body" "F body" at at arrow, arrow, indicative indicative of of Y. Y. Beneath Beneath aa metaphase metaphase with with fluorescent fluorescent Y Y in in center. center. At At right aa V-negative right V-negative interphase interphase and and metaphase, metaphase, both both XX. XX.
Clll CIII \
Fig. Fig. 1l. 11. Same Same as as Fig. Fig. 10 10 following following de destaining staining and and restaining restaining with with carbol carbol fuchsin. fuchsin. Division Division of of
XY and XY and XX XX cells cells is is indicated indicated by by line, line, Y Y at at arrow. arrow. Cells Cells were were karyotyped karyotyped to to confirm confirm fluorescent fluorescent stain diagnosis. stain diagnosis.
Volume 113 Volume 113 Number 44 Number
other aa history other history of of twinning twinning was was obtained. obtained. that fusion fusion of of early early This might This might suggest suggest that zygotes, as zygotes, as readily readily performed performed experimentally experimentally man in mice, in mice, could could be be the the mechanism mechanism in in man (for review (for review see see ref. ref. 14). 14). Skin Skin mottling, mottling, once once aa typical typical striping, striping, was was found found three three times times and and iris heterochromasia iris heterochromasia twice. twice. These These phenotypic phenotypic are characteristic characteristic features features of of some some expressions are expressions of which which have have male tortoiseshell male tortoiseshell cats, cats, many many of They sugsugalso been also been found found to to be be chimeras. chimeras. 22 They that individuals individuals with with such such unusual unusual feafeagest that gest of tures should tures should be be studied studied for for the the possibility possibility of chimeric populations, chimeric populations, easiest easiest undertaken undertaken at at the outset the outset by by discriminating discriminating blood blood group group At present present whole whole body body chimerism chimerism is is studies. At studies. ascertained almost ascertained almost always always (10 (10 of of 11) 11) bebeof intersexuality, intersexuality, and and XX/XV XX/XV lines lines cause of cause are then are then found found to to coexist. coexist. There There should should be be at least at least as as many, many, if if not not more, more, isosexual isosexual (XX/XX and (XX/XX and XV/XV) XV/XV) chimeras. chimeras. Only Only one one has has been been found, found, aa normal normal woman woman with with two two and XX XX cells. cells. 33 blood blood groups, groups, skin skin mottling mottling and An interesting An interesting finding finding in in the the present present case case is the is the identification identification of of an an XY XY line line (3 (3 per per cent) in cent) in the the normal normal left left ovary ovary (Fig. (Fig. 11). 11). To To our knowledge our knowledge this this is is the the second second time time aa YYcontaining in an an containing line line has has been been observed observed in ovary. Previously, ovary. Previously, Butler Butler and and associates associates 44 in in their third their third case case with with XX/XXV XX/XXV chimerism chimerism in the the ovary ovary 9/XXY 9/XXY and and 26/XX 26/XX cells, cells, found in found in the in the testis testis 7/XXY 7/XXY and and 21/XX 21/XX cells. cells. The The probability of probability of selection selection by by tissue tissue culture culture data insufficient insufficient to to refute refute rendered these rendered these data the hypothesis the hypothesis of of gonadal gonadal determination determination by by XX or XX or XY XY chromosome chromosome predominance predominance of of anlage cells. anlage cells. Nevertheless, Nevertheless, they they should should stimustimulate late more more chromosomal chromosomal inventories inventories by by touch touch in the the future. future. preparations preparations in The presence The presence of of aa normally normally functioning functioning in true true hermaphhermaphfemale neuroendocrine female neuroendocrine axis axis in roditism is roditism is attested attested to to by by the the finding finding of of lutea in in the the ovaries ovaries of of some some 25 25 per per corpora lutea corpora cent of cent of these these cases. cases. In In our our case case there there was was not not only evidence only evidence of of feminine feminine development development (psyche, some (psyche, some breast breast tissue, tissue, complete complete MiilMiillerian system, lerian system, regular regular menses menses with with corpus corpus luteum formation luteum formation in in the the ovotestis) ovotestis) but but there there was also was also evidence evidence of of function function of of the the testis testis (masculine facial (masculine facial conformation, conformation, excess excess facial facial and hair, clitoromegaly, hair, clitoromegaly, labial labial scrotalization, scrotalization, and
True hermaphroditism True hermaphroditism and and chimerism chimerism 457 457
Fig. 12. Fig. 12. Portion Portion of of Graafian Graafian follicle follicle from from oophorecoophorectomy of tomy of another another patient. patient. In In the the cumulus cumulus oophorus oophorus is aa maturing is maturing oocyte oocyte with with two two nuclei. nuclei. Potentially Potentially such aa cell such cell may may be be precursor precursor to to chimeric chimeric individindividuals. (Hematoxylin uals. (Hematoxylin and and eosin. eosin. x280. x280. From From Obstet. Obstet. Gynecol. 18: Gynecol. 18: 338, 338, 1961.) 1961.)
labial fusion) labial fusion) .. Not Not enough enough is is known known of of the the efefin humans humans to to elevate elevate fects of fects of hemicastration hemicastration in her gonadotropin her gonadotropin pattern pattern and and the the effect effect of of estrogen therapy estrogen therapy further further complicates complicates the the picture. The picture. The range range of of values values found found is is not not so so in castrates castrates and and high as high as those those encountered encountered in postmenopausal subjects. postmenopausal subjects. The The interesting interesting of regular regular periods periods despite despite and and continuation continuation of independent of independent of cyclic cyclic estrogen estrogen therapy therapy also also requires further requires further study. study. Although Although androgens androgens and have been have been seen seen to to affect affect psychosexual psychosexual and 17 hypothalamic imprintation hypothalamic imprintation in in primates primates17 and and lower species,18 lower species,18 this this effect effect has has never never been been in exogenous exogenous or or endogenous endogenous early early found in found androgen syndromes androgen syndromes in in humans. humans. Our Our patient patient was no was no exception exception to to the the rule. rule. Possibly Possibly the the testis portion testis portion was was abnormal abnormal or or the the amount amount of inducing of inducing substance substance was was insufficient insufficient to to imimprint the print the brain. brain. At At the the local local level level this this dedeapparent ficiency may ficiency may be be reflected reflected by by the the apparent lack of lack of aa Fallopian Fallopian tube tube on on gross gross inspection. inspection. The failure The failure of of the the first first plastic plastic procedure, procedure,
458 Benirschke et 01.
both functional and cosmetic, reinforces our preference of the V-flap vaginoplasty described by Fortunoff, Lattimer, and Edson,lO
Am.
J.
June l:J) 197:: Obs!r!. Gyrlt'col.
and the phallectomy practiced by Jones and Heller.~o
REFERENCES
1. Polani, P. E.: Trans. R. Soc. Lond. S.B 259: 187, 1970. 2. Benirschke, K.: IV International Congress on Human Genetics, Amsterdam, 1971, Excerpta Medica Foundation, in press. 3. Race, R. R., and Sanger, R.: Blood Groups in Man, ed. 5, Philadelphia, 1968, F. A. Davis Company. 4. Butler, L. ]., Snodgrass, G. J. A. I., :France, N. E., Russel, A., and Swain, K. A. ].: Arch. Dis. Child. 44: 666, 1969. 5. Makino, S.: Proc. Sixth World Congr. Ferti!. Steril., 1968; Israel Acad. Sci. Human., Jerusalem, 1970, p. 27 6. Fitzgerald, P. H., Brehaut, L. A., Shannon, F. T., and Angus, H. B.: J. Med. Gen. 7: 383, 1970. 7. Park, I. J., Jones, H. W., and Bias, W. B.: Obstet. Gyneco!. 36: 377, 1970. 8. Kakati, S., Sharma, T., Udupa, K. N., and Chaudhuri, S. P. R.: Ind. J. Med. Res. 59: 104, 1971. 9. Moreno, M. J., and Sanchez, 0.: Acta Cient. Venezolana 22: 14, 1971.
10. Yen, S. S. C., Vela, P., Rankin, J., and Littell, A. S.: J. A. M. A. 211: 1513, 1970. 11. Khudr, G., and Benirschke, K.: AM. J. OBSTET. GY:O