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The Editor
Journal of Genital System & Disorders

Sub: Submission of  Manuscript
Respected Sir,
We are submitting an article titled �Klinefelter�s Syndrome � Unusual Associations� for consideration for publication in your prestigious journal as a �Case Report�. 
On behalf of all the contributors I will act and guarantor and will correspond with the journal from this point onward. 
We hereby transfer, assign, or otherwise convey all copyright ownership, including any and all rights incidental thereto, exclusively to the journal, in the event that such work is published by the journal. 
Thanking you,
Yours� sincerely,
 (Dr KVS Hari Kumar)







TITLE PAGE
Type of article: Case Report
Title of the article: Klinefelter�s Syndrome � Unusual associations
Running Title: Klinefelter�s Syndrome
Contributors :
H. Babul Reddy, MD,DM
K. Neelaveni*, MD,DM
K.V.S. Hari Kumar#, MD,DNB
Department(s) and Institution(s) : 
Consultant Endocrinology, ESI Hospital, Sanath Nagar, Hyderabad � 500018.
*Department of Endocrinology, Osmania General Hospital, Hyderabad. India
#Department of Endocrinology, Command Hospital, Lucknow -226002.U.P. India
Corresponding Author:
K.V.S. Hari Kumar
Email �  HYPERLINK "mailto:hariendo@rediffmail.com" hariendo@rediffmail.com 
Phone- 00-91-945-4674679	Fax � 00-91-522-2851058
Total number of pages: 08	Total number of Figures: One
Word counts: For the Text: 843     For the Abstract: 50
Competing Interests: None Declared
Presentation at Meeting: Nil 
Key Words: Klinefelter�s Syndrome, Growth Hormone deficiency, Ambiguous genitalia

Manuscript
Abstract: Klinefelter�s syndrome (KS) is the most common male sex chromosomal disorder.  KS patients are usually tall and have complete male sexual differentiation. In this report, we present two interesting cases of KS. Our first patient had genital ambiguity and second child had short stature due to growth hormone deficiency. 

Key Words: Klinefelter�s Syndrome; Growth Hormone deficiency; Ambiguous genitalia















Introduction: Klinefelter�s syndrome is the most common chromosomal disorder associated with male hypogonadism and infertility. Klinefelter�s syndrome (KFS) is characterized by X chromosome polysomy with X disomy being the most common variant (1). The syndrome is usually silent before the puberty except for tall stature and difficulties in learning and language. A single Y chromosome and the expression of the testis-determining gene (SRY) are sufficient to bring about testis organogenesis and male sex differentiation (2). Hence, genital ambiguity is unnusual in KFS patients. In this report, we present two interesting patients of KFS with genital ambiguity and short stature respectively. 
Case 1: A 2 year old boy was referred for the evaluation of ambiguous genitalia. He was born at full term to non consanguineous parents by normal vaginal delivery. The mother noticed small penis and passage of urine from a perineal opening at birth. There was no history suggestive of salt losing crisis or seizures in the neonatal period. His statural growth, motor and mental milestones were normal. His height was 85cm (50th centile), upper / lower segment ratio-1.12, arm span-86cm, weight-10 kg (50th centile) and head circumference was 49cm. Genital examination showed micropenis (stretched penile length 1.8 cm), severe chordee, bifid scrotum with both gonads palpable in the scrotal sac and perineal hypospadias (Figure 1). The rest of the systemic examination was normal. Hormonal assay revealed normal thyroid functions with FSH-1.04 miu/ml, LH-0.07 miu/ml and testosterone-0.01ng/ml. HCG (Human Chorionic Gonadotropin) stimulation test done over 72 hours showed a subnormal stimulated response of testosterone (post HCG testosterone � 0.04 ng/ml). Ultrasonography revealed gonads in both scrotal sacs with absence of Mullerian structures. His karyotyping revealed 47 XXY giving a diagnosis of Kilnefelter�s syndrome. The child underwent single stage urethroplasty, penoscrotal transposition and chordee correction. Parents were counselled about the future course of the disease and need of testosterone therapy at a later date.  
Case 2: A male child was first seen in 2004 for evaluation of short stature at the age of 6 years 8 months. He was a product of non consanguineous marriage with a birth weight of 2.2 kg, delivered at full term. His motor, mental milestones and scholastic performance in the school were normal. There were no siblings and parents denied family history of short stature or delayed puberty. Anthropometry revealed: height � 104 cm (<5th centile), weight 23 kg (50th centile), upper/lower segment ratio 0.9, arm span � 105 cm, and no evidence of midline defects, goiter or systemic disease. Estimated bone age was 5 yr by Greulich-Pyle method. Peak GH following clonidine stimulation test was 0.26 ng/mL, confirming the diagnosis of GH deficiency. GH deficiency was confirmed by repeat estimation of stimulated GH, but IGF-1 levels were not evaluated in the patient. His gonadal / thyroid hormones and MRI sella were normal. He was initiated on GH therapy at the age of 7 yrs and received GH therapy for past 6 years with good response and change in height SDS of +2.6. At 14 years of age, he was investigated for lack of spontaneous puberty with a possibility of partial hypopituitarism. His LH � 12.4 IU/L, FSH � 30.5 IU/L and testosterone � 120 ng/dL were suggestive of hypergonadotropic hypogonadism and repeat evaluation confirmed the elevated FSH (41.5 IU/L). External genitalia were P2G1 on Tanner staging and both testes were small and firm in consistency. In view of hypergonadotropic hypogonadism, karyotyping was done which revealed 47XXY. He was started on testosterone supplementation along with growth hormone therapy. 
Discussion: 
In this report we present two interesting cases of Klinefelter�s syndrome with genital ambiguity and short stature respectively. Our first patient had features of undervirilized male suggesting a 46 XY sexual differentiation disorder. Genital anomalies associated with Klinefelter�s syndrome have been reported sporadically. The spectrum of genital abnormality ranges from female external genitalia (complete androgen insensitivity) to micropenis. Androgen insensitivity was proposed initially to explain the disordered genital development in KFS (3). Recent evidence suggests that CAGn trinucleotide polymorphisms in Klinefelter�s patients are responsible for genital ambiguity. A longer CAGn was correlated with features of hypogonadism, such as gynecomastia, smaller testis and penile length (4). 
Another possible explanation for genital ambiguity in KFS may relate to the dosage-sensitive sex reversal (DSS) or DAX-1 gene locus on the X chromosome (5). The presence of two DAX-1 genes can suppress the SRY gene in utero resulting in poor differentiation of gonads located in the scrotal folds.  In Klinefelter�s syndrome, the extra X chromosome (and DAX-1) is generally inactivated. However, incomplete X-inactivation is a possible mechanism of genital ambiguity (5). 
Short stature associated with Klinefelter�s syndrome is reported very rarely. The etiology could be due to associated growth hormone deficiency as seen in our patient and reported previously (6, 7). Other causes could be due to hypothyroidism, autoimmune disorders, renal tubular acidosis and other systemic disorders (8). The limitation of our report is the failure to perform genetic analysis of the androgen receptor gene in both the patients. To conclude, our report highlights the surprising associations of Klinefelter�s syndrome and the need to consider this diagnosis in atypical cases. 





















References:
1) Lanfranco F, Kamischke A, Zitzmann M, Nieschlag E. Klinefelter�s syndrome. Lancet 2004; 364:273�283.
2) McClelland K, Bowles J, Koopman P. Male sex determination: insights into molecular mechanisms. Asian J Androl. 2012;14:164-71. 
3) Hashiyada M, Terada Y, Yaegashi N, Funato T, Yajima A. Complete androgen  insensitivity in a 47,XXY patient with   uniparental disomy for the X chromosome. Am J Med Genet.1999;86: 107�111.
4) Zinn AR, Ramos P, Elder FF, Kowal K, Samango- Sprouse C, Ross JL. Androgen receptor CAGn repeat length  influences phenotype of 47,XXY (Klinefelter)  syndrome. J Clin Endocrinol Metab. 2005;90:5041�46.
5) Iitsuka Y, Bock A, Nguyen DD, Samango-Sprouse CA, Simpson JL, Bischoff FZ: Evidence of skewed X chromosome inactivation in 47,XXY and 48,XXYY Klinefelter patients. Am J Med Genet. 2001;98:25�31.
6) Bah�llo-Curieses MP, Fournier-Carrera M, Mor�n-L�pez J, Mart�nez-Sopena MJ. Klinefelter syndrome and short stature: an unusual combination. Endocrine. 2011;39:294-5.
7) Mazen I, El-Ruby M, El-Bassyouni HT. Variable associations of Klinefelter syndrome in children. J Pediatr Endocrinol Metab. 2010; 23:985-9. 
8) Jebasingh F, Paul TV, Spurgeon R, Abraham S, Jacob JJ. Klinefelter's syndrome with renal tubular acidosis: impact on height. Singapore Med J. 2010;51:e24-6.


Legend for Figures:
Figure 1: Clinical image showing micropenis, bifid scrotum (A) and hypospadias (B) 





















Contributions
All authors contributed equally in managing the cases, drafting the manuscript. All authors acknowledge that they have seen the final manuscript before submission for publication. 

Conflict of Interest
All authors have nothing to disclose

Source of Funding
Not applicable

Patients Consent
We certify that necessary informed consent was obtained from the patient and his parents for publication of the clinical photograph in print or electronic media. 
















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