Detection of a frequent duplicated CYP21A2 gene carrying a Q318X mutation in a general population with quantitative PCR methods.

Earlier we had reported a large prevalence of the Q318X mutation in the CYP21A2 gene with 35.3% in Tunisian patients with a classical form of 21-hydroxylase deficiency, in contrast with 0.5% to 13.8% as described in other populations. Here we present the analysis of the Q318X mutation in a healthy Tunisian population. We screened 136 individuals by the polymerase chain reaction (PCR)/random fragment length polymorphism method, which was confirmed by direct sequencing. Surprisingly, 17 Q318X carriers were identified, for a carrier frequency of 12.5% (95% confidence interval: 7.86-19.20). To explain this unexpectedly high rate we suggest that the haplotype with Q318X mutation and duplicated CYP21A2 gene could be very frequent in the Tunisian population. To test our hypothesis, we used 2 different quantitative PCR methods, that is, multiplex ligation-dependent probe amplification and real-time PCR. The molecular studies showed the presence of a duplicated CYP21A2 gene in all 17 heterozygous Q318X mutation carriers. In addition, both quantitative PCR methods used in this study represent a sensitive and useful approach to detecting copy number variations of the CYP21A2 gene. We have identified a very high frequency of carriers with duplicated CYP21A2 gene haplotype in a healthy Tunisian population. This finding complicates the molecular diagnosis of 21-hydroxylase deficiency and we recommend that, whenever a Q318X is identified, the structure of the CYP21A2 region should be determined to discriminate between the severe Q318X mutation and the normal Q318X variant.