Isolated aldosterone synthase deficiency caused by simultaneous E198D and V386A mutations in the CYP11B2 gene

Isolated deficiencies in aldosterone biosynthesis are caused by mutations in the CYP11B2 (aldosterone synthase) gene. Patients with this deficiency have impaired aldosterone synthesis, exhibit increased plasma renin activity, secrete increased amounts of the steroid precursors DOG, corticosterone, and 18OHDOC, and are subject to salt wasting and poor growth. Two forms are generally distinguished. The first, corticosterone methyloxidase type I (CMO I or type 1 deficiency), is characterized by no detectable aldosterone secretion, a low or normal secretion of the steroid 18OHB, and are always found to have mutations that completely inactivate the encoded CYP11B2 enzyme. The second form (CMO II or type 2 deficiency) may have low to normal levels of aldosterone, but at the expense of greatly increased secretion of its immediate precursor 18OHB. These patients usually have a CYP11B2 enzyme with some residual enzymatic activity especially 11 beta-hydroxylase activity. We have studied two twins with an isolated aldosterone synthase activity who have a clinical profile typical of the type 1 deficiency. Their CYP11B2 genes are homozygous for three sequence changes, R173K, E198D, and V386A. In transfection assays these substitutions individually have modest effects on the encoded enzyme, but when found together they result in an enzyme with a decreased 11 beta-hydroxylase activity, a large decrease of 18-hydroxylase activity, and no detectable 18-oxidase activity. This residual activity is more typical of that observed in patients classified as having CMO II deficiency, rather than CMO I deficiency, where no activity is detectable. This disparity between the CYP11B2 enzyme with residual activity and a clinical phenotypic typical of the type 1 deficiency, suggests that phenotype genotype relationships are not yet fully understood.