A Case of de la Chapelle Syndrome

Abstract

A rare disorder of sex development (DSD) linked to a 46,XX karyotype is characterized by male externalgenitalia, which can range from typical to atypical, often accompanied by testosterone deficiency. A 3-year-old child who appeared phenotypically male was brought to the hospital by his parents due to concernsabout ambiguous genitalia. A comprehensive series of pathological tests and radiological imaging studieswere conducted to ascertain the underlying cause of his presentation. Karyotyping revealed a 46,XXgenotype, while magnetic resonance imaging (MRI) results indicated the presence of both testes and aMüllerian remnant. Consequently, the diagnosis was established as the de la Chapelle syndrome. This casereport aims to highlight various imaging findings associated with this syndrome.

Full text

Received 08/15/2023
Review began 10/13/2023
Review ended 10/30/2023
Published 11/02/2023
© Copyright 2023
Thaker et al. This is an open access article
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.
A Case of de la Chapelle Syndrome
Nirja Thaker , Pratapsingh Parihar , Rajasbala Dhande , Nishant Raj , Bhavik Unadkat
1. Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and
Research (Deemed to be University), Wardha, IND
Corresponding author: Nirja Thaker, nirja26@gmail.com
Abstract
A rare disorder of sex development (DSD) linked to a 46,XX karyotype is characterized by male external
genitalia, which can range from typical to atypical, often accompanied by testosterone deficiency. A 3-year-
old child who appeared phenotypically male was brought to the hospital by his parents due to concerns
about ambiguous genitalia. A comprehensive series of pathological tests and radiological imaging studies
were conducted to ascertain the underlying cause of his presentation. Karyotyping revealed a 46,XX
genotype, while magnetic resonance imaging (MRI) results indicated the presence of both testes and a
Müllerian remnant. Consequently, the diagnosis was established as the de la Chapelle syndrome. This case
report aims to highlight various imaging findings associated with this syndrome.
Categories: Pediatrics, Radiology
Keywords: ambiguous genitalia, pediatric mri, de la chapelle syndrome, virilization, disorder of sex development
(dsd)
Introduction
The de la Chapelle syndrome, also known as 46,XX testicular disorder of sex development (DSD) [1], is an
exceptionally rare genetic disorder that influences sexual development. Within this condition, individuals
with a female karyotype (46,XX) experience undescended testes and ambiguous genitalia stemming from
irregular gonadal and genitalia development during fetal gestation [2]. Collectively, DSD constitute a
multifaceted and diverse array of conditions that can exert substantial impacts on an individual's physical,
psychological, and social well-being. Enhanced comprehension, awareness, and access to appropriate care
and support can alleviate the burdens associated with DSD and foster optimal health outcomes for those
affected.
In approximately 90% of cases, this syndrome is attributed to the presence of the SRY gene on the Y
chromosome, which is responsible for male reproductive development. Remarkably, it becomes entangled in
the genetic information exchange during meiosis in the father [3]. The SRY gene is typically situated near the
terminus of the Y chromosome, yet during recombination, it translocates to the X chromosome [3-5]. These
disorders manifest in various forms and impact the physical, hormonal, and genetic facets of sex
development. Affected children are usually raised as males and develop a male gender identity, although
they may contend with undescended testes and potential infertility owing to azoospermia [6]. Structural
chromosomal anomalies, including 46,XX male syndrome, represent the second most prevalent genetic
cause of azoospermia after the Klinefelter syndrome [7].
DSD [1] constitute a category of congenital disorders characterized by aberrations in chromosomal, gonadal,
or anatomical sex development. Globally, it is estimated that DSD affects between one in 2,000 and 4,500
newborns. However, precise prevalence figures remain elusive due to the lack of universal diagnostic
standards, reporting inconsistencies, and the stigma associated with DSD in certain cultures. Estimates
suggest a higher prevalence of DSD in India, ranging from one in 500 to one in 2,000 births, exceeding the
global average. DSD confers a substantial disease burden due to its potential long-term implications for
physical health, fertility, sexual function, and mental well-being. Individuals with DSD often necessitate
sophisticated medical interventions, such as hormone therapy, surgical procedures, and ongoing health
outcome monitoring. Access to adequate care may be limited in certain regions. Moreover, DSD can
engender considerable emotional and psychosocial challenges, including feelings of stigma, discrimination,
and social isolation. Those with DSD may grapple with gender identity, sexual orientation, relationships,
and access to suitable education, employment, and healthcare resources.
The reported incidence of 46,XX male syndromes among newborns is approximately one in 20,000. In 90%
of cases, the external genitalia exhibit full virilization, leading to detection post puberty, accompanied by
symptoms like hypogonadism, gynecomastia, and/or infertility [1]. Clinical presentation in the remaining
10% without a Y chromosome includes hypospadias, undescended testes, or various degrees of inadequate
virilization in the external genitalia (sex-determining region Y negative). Additional clinical features
comprise short stature and normal mental development [8]. The de la Chapelle syndrome carries a
substantial disease burden, encompassing potential infertility, challenges related to gender identity, and
social stigmatization. Lifelong medical management may also be imperative for affected individuals,
1 1 1 1 1
Open Access Case
Report DOI: 10.7759/cureus.48150
How to cite this article
Thaker N, Parihar P, Dhande R, et al. (November 02, 2023) A Case of de la Chapelle Syndrome. Cureus 15(11): e48150. DOI
10.7759/cureus.48150

including hormone replacement therapy and surgical interventions.
Case Presentation
A 3-year-old patient, phenotypically male, received a diagnosis of undescended testes during their neonatal
examination. As the child continued to grow, their father observed atypical genitalia and promptly sought
medical evaluation at the hospital. Upon examination, the patient's genitalia exhibited ambiguity, as
depicted in Figure 1. The patient's birth history indicates a full-term delivery with a birth weight of 1.75 kg.
There is no known history of this disorder in other family members, and the mother denied using any
hormones or drugs during her pregnancy.
FIGURE 1: Ambiguous genitalia in the child
During the laboratory investigations, the levels of dihydrotestosterone (DHT), androstenedione, and
testosterone were found to fall within the established range for normalcy (DHT=22.37 ng/dl,
androstenedione=0.3 ng/dl, and testosterone=4.9 ng/dl) when compared to the standard male hormone
levels for that specific age group. Subsequently, a post-human chorionic gonadotropin (HCG) stimulation
test indicated an elevation in testosterone levels (post-HCG stimulation: testosterone=36.5 ng/dl,
DHT=86.39 ng/dl, and androstenedione=0.3 ng/dl). As seen in many cases of external genitalia ambiguity in
pre-pubertal children, the levels of DHT, androstenedione, and testosterone were found to be in normal
range for age. In this case also, we found them to be in normal range. The beta-HCG stimulation also
revealed normal response (fourfold increase in DHT, androstenedione, and testosterone levels). Karyotyping
analysis revealed a chromosomal complement of 46,XX.
As depicted in Figure 2 and Figure 3, bilateral testes were observed within the inguinal region. A phallus,
comprising the corpus cavernosum and corpus spongiosum muscle with an inferiorly positioned urethral
orifice (hypospadias), was visualized. Concentric labioscrotal folds surround the phallus. A cystic lesion was
2023 Thaker et al. Cureus 15(11): e48150. DOI 10.7759/cureus.48150 2 of 6

detected in the midline, anterior to the rectum, and posterior to the urinary bladder within the pelvic region.
The pelvic bones, sacroiliac joints, hip joints, joint spaces, articular margins, and urinary bladder all
exhibited normal appearances. The visualized spine appeared unremarkable.
FIGURE 2: Remnant of the Müllerian duct seen as the hyperintense
structure posterior to the urethra and anterior to the rectum
2023 Thaker et al. Cureus 15(11): e48150. DOI 10.7759/cureus.48150 3 of 6

FIGURE 3: Presence of bilateral testes on the MR T2WI axial section of
the pelvis
MR T2WI: magnetic resonance T2-weighted image
The patient has been diagnosed with 46,XX testicular DSD, also referred to as the de la Chapelle syndrome
[1], based on the provided information. This condition is a rare genetic disorder characterized by individuals
with a female karyotype (46,XX) who exhibit undescended testes and ambiguous genitalia due to the
abnormal development of the gonads and genitalia during fetal development [2].
The magnetic resonance imaging (MRI) results reveal the presence of a phallus with corpus cavernosum and
corpus spongiosum, concentric labioscrotal folds surrounding the phallus, indicative of ambiguous genitalia,
and an inferiorly located urethral orifice, a condition known as hypospadias. Additionally, a midline cystic
lesion located anterior to the rectum and posterior to the urinary bladder in the pelvis is most likely a
Müllerian duct remnant, a characteristic feature often observed in cases of 46,XX testicular DSD.
Undescended testes are another distinctive symptom associated with 46,XX testicular DSD.
Discussion
SRY-positive XX males possess two X chromosomes, one of which harbors genetic material from the Y
chromosome, notably the SRY gene. This specific gene endows them with a male phenotype, despite their
chromosomal configuration being more characteristic of females [3]. However, XX males lack the SRY gene
(SRY negative), and in such cases, an alternative gene on one of the autosomes may instigate the
development of a male phenotype. This condition arises from an erroneous exchange of genetic material
between chromosomes, a process known as translocation, which occurs randomly during the development of
the affected individual's father's sperm cells. The SRY gene is typically located near the terminus of the Y
chromosome and can translocate to the X chromosome during recombination [3-5]. Remarkably, even
without a Y chromosome, offspring from a sperm cell carrying an X chromosome with the SRY gene will
develop as males. This condition is termed SRY-positive 46,XX testicular DSD [6].
The case report pertains to a patient presenting with a suspected sexual differentiation disorder, specifically
identified as the de la Chapelle syndrome, characterized by the presence of a 46,XX karyotype in an
individual with a male phenotype. This syndrome arises due to an error in the sexual differentiation process,
leading to the formation of testes in a chromosomal female. In instances where clinical and/or laboratory
symptoms of androgen deficiency manifest during puberty, testosterone replacement therapy should be
administered. Additionally, for cases involving external genital anomalies, timely surgical correction is
recommended to avert social and sexual challenges [1]. Although the testis morphology is typically normal
in infancy, the hyalinization of seminiferous tubules in early childhood results in the loss of spermatogonia
[9,10].
In this case, the patient was initially diagnosed with undescended testes during routine neonatal care.
Subsequently, his father sought medical evaluation for atypical genitalia. A thorough examination revealed
unambiguous genitalia; hormonal tests indicated average androgen levels. A post-HCG stimulation test
confirmed adequate testosterone production, signifying functional testes. An MRI scan disclosed the
presence of a phallus with corpus cavernosum and corpus spongiosum muscle, a concentric labioscrotal fold
surrounding the phallus, and a linear midline cystic lesion in the pelvis, potentially a Müllerian duct
2023 Thaker et al. Cureus 15(11): e48150. DOI 10.7759/cureus.48150 4 of 6

remnant. In a patient presenting with male genitalia and testicular tissue, the presence of a 46,XX karyotype
aligns with the de la Chapelle syndrome. A midline cystic lesion may also suggest the persistence of a
Müllerian duct remnant, a common occurrence in individuals with sexual differentiation challenges.
This case underscores the imperative need for a comprehensive evaluation of patients suspected of having
sexual differentiation issues, encompassing hormonal assessments, karyotyping, and imaging tests to
uncover underlying genetic and anatomical abnormalities. The management of the de la Chapelle syndrome
typically involves a multidisciplinary approach, incorporating endocrinologists, geneticists, and urologists.
Treatment options are guided by the patient's age and degree of virilization. In cases involving ambiguous
genitalia, such as the one described here, surgical intervention is usually recommended to remove any
remaining Müllerian duct remnants and correct hypospadias. The specific surgical technique may vary
depending on the size of the Müllerian duct remnant and the patient's future fertility desires. It may include
procedures such as vaginectomy, uterine removal, and gonadectomy. Moreover, to address concerns related
to gender identity and sexuality, psychological counseling and support may be deemed necessary.
The management should be centered on three primary domains: early stabilization, precise diagnosis,
gender of rearing decisions, and surgical intervention and hormonal treatment planning. The fundamental
aims of surgery are to achieve the best aesthetic outcomes possible, to retain sexual functioning, to preserve
fertility if possible, and to reduce the risk of malignancy in the dysgenetic gonad. Delaying surgery until the
child is old enough to confirm their gender identity is frequently advocated. The date of gonadectomy is
determined by the risk, gender of raising, and gonad functionality. In individuals to be raised as females,
removal is recommended during genitoplasty. Males should have orchidopexy and a biopsy after puberty.
Streak gonads should be removed as soon as possible [11].
The surgical and medical treatment helps in improving the patient's quality of life. But infertility is usually
seen in these patients. Psychosexual development is influenced by societal and cultural norms, in utero
androgen exposure, genetic variations, and familial dynamics. The de la Chapelle syndrome is linked to
long-term mental issues, such as low self-esteem, sadness, and so on, as well as physical complications, such
as infertility. Early counseling and therapy for both the patient and his family should prevent the
psychosocial influence on the individual's quality of life.
In the absence of radiological evidence of the existence or absence of testes, anti-Müllerian hormone (AMH),
which acts as a marker of testicular tissue, is used to investigate ambiguous genitalia. Gonadal dysgenesis,
testicular regression syndrome, disappearing testicular syndrome, and persistent Müllerian duct syndrome
are potential reasons of low AMH in patients. Individuals who respond normally to beta-HCG are also likely
to have androgen insensitivity syndrome, an AMH receptor deficiency, or exposure to endocrine disruptors
such as phenytoin. Cloaca, urogenital sinus, rectovaginal fistula, and numerous congenital duplications such
as caudal duplication are also observed in the differential diagnosis [11].
The main limitation of the study is the inability to follow-up the case. Other limitations include monetary
factor (mainly for investigations like fluorescence in situ hybridization (FISH)) and social factors leading to
parents hiding the patient's condition.
Conclusions
The patient has been diagnosed with 46,XX testicular DSD, also referred to as the de la Chapelle syndrome,
based on the provided information. This is a rare genetic condition characterized by individuals with the
female karyotype (46,XX) exhibiting undescended testes and ambiguous genitalia due to the abnormal
development of the gonads and genitalia during fetal development. The MRI results reveal the presence of a
phallus with corpus cavernosum and corpus spongiosum, concentric labioscrotal folds surrounding the
phallus, indicative of ambiguous genitalia, and an inferiorly positioned urethral orifice, a condition known
as hypospadias. Additionally, a midline cystic lesion located anterior to the rectum and posterior to the
urinary bladder in the pelvis is most likely a remnant of the Müllerian duct, commonly observed in 46,XX
testicular DSD cases. Undescended testes are another distinguishing feature of this condition. The
management and treatment of the de la Chapelle syndrome typically involve a multidisciplinary team of
endocrinologists, geneticists, and urologists. The patient's age and degree of virilization influence the
treatment choice. In the case of the patient in question, the presence of ambiguous genitalia indicates a high
level of virilization. Consequently, surgical intervention is usually recommended to remove the Müllerian
duct remnants and correct the hypospadias. The specific surgical approach may vary depending on the size
of the Müllerian duct remnant and the patient's future fertility desires, and it may involve procedures such
as vaginectomy, uterine removal, and gonadectomy. To address concerns related to gender identity and
sexuality, psychological counseling and support may be necessary. The de la Chapelle syndrome is typically
managed through hormone replacement therapy to promote the development of secondary sexual
characteristics alongside surgical interventions to address genital anomalies. In this case, further
assessment and treatment planning by an endocrinologist and a urologist may be warranted to determine
the most appropriate course of action.
Additional Information
2023 Thaker et al. Cureus 15(11): e48150. DOI 10.7759/cureus.48150 5 of 6

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
References
1. Zenteno-Ruiz JC, Kofman-Alfaro S, Méndez JP: 46,XX sex reversal . Arch Med Res. 2001, 32:559-66.
10.1016/s0188-4409(01)00322-8
2. Abdel-Hamid IA, Elsobky ES, El-Saied M: Disorders of sex determination . Genetics of Male Infertility. Arafa
M, Elbardisi H, Majzoub A, Agarwal A (ed): Springer, Midtown Manhattan, New York City; 2020.
3. Vorona E, Zitzmann M, Gromoll J, Schüring AN, Nieschlag E: Clinical, endocrinological, and epigenetic
features of the 46,XX male syndrome, compared with 47,XXY Klinefelter patients. J Clin Endocrinol Metab.
2007, 92:3458-65. 10.1210/jc.2007-0447
4. Chen H: XX male. Atlas of Genetic Diagnosis and Counseling. Springer, Midtown Manhattan, New York City;
2012. 10.1007/978-1-4614-1037-9_250
5. Margarit E, Coll M D, Oliva R, et al.: SRY gene transferred to the long arm of the X chromosome in a Y-
positive XX true hermaphrodite. Am J Med Genet. 2000, 90:25-8. 10.1002/(sici)1096-
8628(20000103)90:1<25::aid-ajmg5>3.0.co;2-5
6. 46,XX testicular difference of sex development . (2022). Accessed: September 29, 2022:
https://medlineplus.gov/genetics/condition/46xx-testicular-difference-of-sex-development/.
7. Röpke A, Tüttelmann F: Mechanisms in endocrinology: aberrations of the X chromosome as cause of male
infertility. Eur J Endocrinol. 2017, 177:R249-R259. 10.1530/EJE-17-0246
8. Ergun-Longmire B, Vinci G, Alonso L, et al.: Clinical, hormonal and cytogenetic evaluation of 46,XX males
and review of the literature. J Pediatr Endocrinol Metab. 2005, 18:739-48. 10.1515/JPEM.2005.18.8.739
9. Boucekkine C, Toublanc JE, Abbas N, et al.: Clinical and anatomical spectrum in XX sex-reversed patients,
relationship to the presence of Y-specific DNA sequences. Clin Endocrinol. 1994, 40:733-42. 10.1111/j.1365-
2265.1994.tb02506.x
10. Abbas NE, Toublanc JE, Boucekkine C, et al.: A possible common origin of “Y-negative” human XX males
and XX true hermaphrodites. Hum Genet. 1990, 84:356-60. 10.1007/BF00196234
11. Mehmood KT, Rentea RM: Ambiguous Genitalia and Disorders of Sexual Differentiation . StatPearls
[Internet]. StatPearls Publishing, Treasure Island (FL); 2023.
2023 Thaker et al. Cureus 15(11): e48150. DOI 10.7759/cureus.48150 6 of 6