Spleen function is reduced in individuals with NR5A1 variants with or without DSD: a cross-sectional study.

NR5A1 is a key regulator of sex differentiation and has been implicated in spleen development through transcription activation of TLX1. Concerns exist about hypo- or asplenism in individuals who have a difference of sex development (DSD) due to an NR5A1 disease-causing variant. We aimed to assess spleen anatomy and function in a clinical cohort of such individuals, and in their asymptomatic family member carriers. Cross-sectional assessment in 22 patients with a DSD or primary ovarian insufficiency and five asymptomatic carriers from 18 families, harboring 14 different NR5A1 variants. Spleen anatomy was assessed by ultrasound, spleen function by peripheral blood cell count, white blood cell differentiation, percentage of non-switched memory B-cells, specific pneumococcal antibody response, % pitted red blood cells and Howell-Jolly Bodies. Patients and asymptomatic heterozygous individuals had significantly decreased non-switched memory B-cells compared to healthy controls, but higher than asplenic patients. Thrombocytosis and spleen hypoplasia were present in 50% of heterozygous individuals. Four out of five individuals homozygous for the previously described p.(Arg103Gln) variant had asplenia. Individuals harbouring a heterozygous NR5A1 variant that may cause DSD have a considerable risk for functional hyposplenism, irrespective of their gonadal phenotype. Splenic function should be assessed in these individuals, and if affected or unknown, prophylaxis is recommended to prevent invasive encapsulated bacterial infections. The splenic phenotype associated with NR5A1 variants is more severe in homozygous individuals and is, at least for the p.(Arg103Gln) variant, associated with asplenism.

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