Disponible en ligne sur

ScienceDirect
www.sciencedirect.com

Annales d’Endocrinologie 75 (2014) 88–97

Journées Klotz 2014

New approaches to the Klinefelter syndrome

Nouvelles approches du syndrome de Klinefelter
Eberhard Nieschlag a,∗,b , Steffi Werler a , Joachim Wistuba a , Michael Zitzmann a
aCentre of Reproductive Medicine and Andrology, University of Münster, D-48129 Münster, Germany
b Center of Excellence in Genomic Medicine Research, King Abdulaziz University, Jeddah, Saudi Arabia

Abstract
The Klinefelter syndrome (KS), with an incidence of 1 to 2 per 1000 male neonates, is one of the most frequent congenital chromosome
disorders. The 47,XXY karyotype causes infertility, testosterone deficiency and a spectrum of further symptoms and comorbidities. In recent years,
significant progress has been made in the elucidation of the pathophysiology and the treatment of the KS. It became clear that, to a large extent,
the clinical picture is determined by gene dosage effects of the supernumerary X-chromosome. The origin of the extra X-chromosome from either
the father or the mother influences behavioural features of patients with KS. The CAGn polymorphism of the androgen receptor, located on the
X-chromosome, has a distinct impact on the KS phenotype. KS predisposes to the metabolic syndrome and its cardiovascular sequelae, contributing
to the increased mortality of patients with KS. Neuroimaging studies have correlated anomalies in brain structures with psychosocial problems.
The unexpected possibility to produce pregnancies and live birth with either ejaculated sperm – about 8% of KS men have a few sperm in semen –
or with sperm extracted from individual tubules obtained by testicular biopsy can be considered a breakthrough. Testosterone substitution requires
further optimisation in terms of when to initiate therapy and which preparations and dosages to use. Recently developed animal models help to
further elucidation the genetic and pathopysiological basis and may lead to new therapeutic approaches to KS.
© 2014 Elsevier Masson SAS. All rights reserved.

Keywords: Klinefelter; 47,XXY karyotype

Résumé
Le syndrome de Klinefelter (KS) avec une incidence de 1 à 2 pour mille nouveaux-nés de sexe masculine, est l’un des désordres chromosomiques
congénitaux les plus frequents. Le caryotype 47,XXY entraîne une infertilité et un deficit en testosterone et un éventail d’autres symptômes et
co-morbidités. Au cours des dernières années, des progrès significatifs ont été faits dans l’élucidation des mécanismes physiopathologiques et le
traitement du KS. Il est clair aujourd’hui que, dans une large mesure, le tableau clinique est déterminé par un effet dose-gène sur le chromosome X
surnuméraire. L’origine paternelle ou maternelle de cet extra-chromosome X influence le comportement des patients avec un KS. Le polymorphisme
CAGn du récepteur des androgènes, situé sur le chromosome X, a un impact différent sur le phénotype du KS. Le KS prédispose au syndrome

DOIs of original articles: http://dx.doi.org/10.1016/j.ando.2014.04.010, http://dx.doi.org/10.1016/j.ando.2014.03.004, http://dx.doi.org/10.1016/j.ando.2014.04.

006, http://dx.doi.org/10.1016/j.ando.2014.04.011, http://dx.doi.org/10.1016/j.ando.2014.03.008, http://dx.doi.org/10.1016/j.ando.2014.03.010, http://dx.doi.org/
10.1016/j.ando.2014.04.002, http://dx.doi.org/10.1016/j.ando.2014.04.004, http://dx.doi.org/10.1016/j.ando.2014.03.001, http://dx.doi.org/10.1016/j.ando.2014.03.
003, http://dx.doi.org/10.1016/j.ando.2014.03.009, http://dx.doi.org/10.1016/j.ando.2014.03.011, http://dx.doi.org/10.1016/j.ando.2014.04.001, http://dx.doi.org/
10.1016/j.ando.2014.04.003, http://dx.doi.org/10.1016/j.ando.2014.04.005, http://dx.doi.org/10.1016/j.ando.2014.03.002, http://dx.doi.org/10.1016/j.ando.2014.
03.005.
∗ Corresponding author.

E-mail address: eberhard.nieschlag@ukmuenster.de (E. Nieschlag).

http://dx.doi.org/10.1016/j.ando.2014.03.007
0003-4266/© 2014 Elsevier Masson SAS. All rights reserved.
 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97 89

métabolique et aux complications cardiovasculaires, contribuant à une mortalité accrue chez les patients avec un KS. Les études neuro-imageries
ont montré une corrélation entre les anomalies de la structure cérébrale et les difficultés psycho-sociales. La possibilité inattendue d’obtenir des
grossesses avec naissance vivante à partir, soit d’un sperme éjaculé – environ 8 % des KS ont quelques spermatozoids dans l’éjaculat – soit avec
du sperme extrait à partir des tubules individuelles obtenues après biopsie testiculaire peut être considérée comme une avancée. La substitution
en testosterone nécessite encores des optimisations en termes d’âge auquel initier le traitement, de type de préparation et de dosage. Récemment,
le développement de modèles animaux a aide à élucider plus avant les bases génétiques et physiopathologiques de ce syndrome ce qui permet
d’envisager de nouvelles approches thérapeutiques du KS.
© 2014 Elsevier Masson SAS. Tous droits réservés.

Mots clés : Klinefelter ; 47,XXY karyotype

1. Frequent syndrome, often overlooked metabolic syndrome, osteoporosis, breast abnormalities, throm-
boembolism, psychosocial and neurologic problems may also
The Klinefelter syndrome (KS) – first described in 1942 [1] – be caused by accompanying chromosomal and genetic abnor-
is the most frequent type of congenital chromosomal disorder malities.
in males and is caused by aneuploidy of the sex chromosomes. Over the past decade, several reviews have aimed to improve
Primarily, the KS is considered a disturbance of the exocrine and the level of information about this multifaceted syndrome and to
endocrine function of the testes. Indeed, infertility and testos- increase the diagnostic frequency of this disease entity [7–10]. In
terone deficiency are the key symptoms directing the patient the current paper we refer the reader to this general information
either to the endocrinologist, to the andrologist or to fertility about the KS and highlight here areas where significant progress
centres. However, beyond these symptoms of hypogonadism the has recently been made.
KS is associated with a number of comorbidities and increased
mortality of the affected men compared to the general population 2. New genetic findings
[2–5] (Table 1).
It is suspected that these comorbidities arouse the physicians’ 2.1. X-chromosome inactivation and gene dosage effects
attention more frequently than direct symptoms of hypogo-
nadism, but the underlying disorder remains unrecognized and It becomes increasingly obvious that the clinical picture of
only the comorbidity is treated [6,7]. The proper diagnosis hav- KS patients is caused by gene dosage effects of the super-
ing been made, until recently comorbidities were considered numerary X-chromosome. Similar to women, the additional
primarily a consequence of the lack of testosterone. However, X-chromosome in KS patients is silenced due to the process
evidence is emerging that features such as increased height, of X-inactivation [11–14]. One key player within this process
is the non-coding RNA XIST, which spreads over the entire
Table 1
X-chromosome that becomes inactivated in cis and leads to hete-
Comorbidities in Klinefelter syndrome: prevalence and mortality. rochromatization and gene-silencing [15]. The methylation level
of the CpG-island within the XIST promotor region can give
Incidence, Ref. Mortality Ref.
% (SMRa )
evidence about the X-chromosome inactivation status.
In KS patients, it was shown that the XIST DNA-methylation
Gynecomastia 38 [8] level was comparable to women, but significantly different from
Breast cancer 0.3 [2] 29 [2]
Thrombosis 4.7 [5] 8 [3]
men, indicating correct X-chromosome inactivation [14]. Other
Pulmonary embolism 2.3 [5] 6 [3] studies further demonstrated expression of the XIST gene in
Metabolic syndrome 44 [110] blood lymphocytes [12]. As approximately 15% of the X-linked
Type 2 diabetes 10 [110] 6 [3] genes escape the process of X-inactivation [16,17], these genes
Erectile dysfunction 25 [111] can be considered as the genetic background of KS [18].
Osteopenia 40 [23]
Osteoporosis 10 [33]
These genes that are expressed from the active and the inac-
Hip fracture ? 39 [3] tive allele are located across the entire X-chromosome, but are
Maldescended testes 27 [8] predominantly located in the pseudo-autosomal region (PAR),
Mediastinal tumors 0.4 [5] where recombination between the X and Y chromosome takes
Epilepsy 5.5 [5] 7 [3] place [19]. Especially the escape of genes located in the pseu-
Mental retardation 4.2 [5]
Delayed verbal development 40 [112]
doautosomal region of the X and Y chromosome (PAR) is of
Language disorder 70–80 [68] interest in KS patients as this causes the presence of three active
Legasthenia 50–70 [68] copies. The escape of the PAR genes SHOX, PCGH11XY and
Learning difficulties 75 [112] SYBL1 was demonstrated epigenetically in blood lymphocytes
ADHS 63 [67] of KS patients [14,20]. It is speculated that this ‘female’ expres-
Autism 48 [113]
sion pattern in e.g. Leydig cells, which normally only have
a SMR: standardized mortality rate, i.e. predicted deaths [3]. a 46,XY karyotype, compromise their function. Nevertheless,
90 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97
complete inactivation and escape of X-chromosomal genes has
to be proven in the tissue of interest, as expression/methylation
in blood might not reflect the tissue-specific inactivation pat-
tern. It was shown that in female cells, many of these genes
show inter-individual variation of expression and also tissue-
specificity [21,22].
The only study so far examining the KS methylomic and
transcriptomic profile not only in the blood is a case report ana-
lyzing the prefrontal cortex and cerebellum of a KS patient [23].
Numerous autosomal regions with a different DNA-methylation
pattern compared to male and female controls were found
as well as tissue-specific expression differences of autosomal
and X-chromosomal genes. Regarding genes escaping from X-
inactivation, no consistent pattern of transcription was found,
some of the genes were upregulated in the KS patient, others
were down-regulated. Thus, a hint was found that alterations in
gene expression of those genes normally escaping X-inactivation
in females exist in KS patients and furthermore, that many auto-
somal genes were altered. It can be concluded that the phenotypic
variation in KS patients can arise by autosomal alterations and
the extent to which genes escape X-inactivation. Nevertheless, it
is important to keep in mind that these data derive from a single
case report. In addition to genes escaping from X-inactivation,
the high phenotypic variation of the syndrome is also explained
by other genetic and epigenetic effects such as parental ori-
gin of the X-chromosome, genetic polymorphisms and skewed
X-inactivation of the X-chromosome.
2.2. Parental origin of the supernumerary X-chromosome
In KS patients, the extra X-chromosome can be inherited from
both parents. In approximately 50% of the cases, it originates
from the father due to non-disjunctions during meiosis I (MI).
The paternal origin of the additional X-chromosome can only
arise by MI errors as errors in meiosis II (MII) would lead to
XXX or XYY zygotes. The other 50% are caused by maternal
errors that are variable in origin: failure during maternal MI
account for 48% of maternal XXY, in 29% a failure during MII
occurs and in 7% of the maternal cases, the origin of the error
remains unclear. In addition 16% of the maternal cases can arise
from errors in early mitotic divisions of the zygote [24].
The parental origin of the supernumerary X-chromosome
has been suggested to play a pivotal role in clinical fea-
tures of KS [10,25]. The presence of two identical or two
different X-chromosomes might possibly interfere with the fine-
tuned process of X-chromosome inactivation. Especially for
the variability of the KS phenotype parent-of-origin (of the
extra X-chromosome) effects have been proposed. Parent-of-
origin effects have been demonstrated regarding cognition and
behavioural aspects. KS patients with a maternally inherited X-
chromosome showed higher scores on schizotypical traits [26].
Another study also showed an influence of the parental inher-
itance of the supernumerary X-chromosome on the variation
of the cognitive phenotype in KS patients by demonstrating
more frequent speech and language problems in KS patients
with a paternally inherited extra X-chromosome [27]. How-
ever, other studies do not support this hypothesis [28,29]. It
further remains unknown if the inheritance of the supernumer-
ary X-chromosome accounts for other phenotypic differences,
e.g. infertility or the metabolic syndrome.
2.3. The androgen receptor CAGn polymorphism
The androgen receptor, which is located on the X-
chromosome, contains a highly polymorphic trinucleotid repeat
(CAGn) in exon 1 [30]. The length of this repeat normally
varies between 9 and 37 [31] and is correlated with physiolog-
ical androgen effects. The CAG repeat length in KS patients
causes phenotypical variation by affecting height, arm span,
cholesterol, haematocrit and haemoglobin [18,32]. The positive
correlation to height and arm span could possibly be related to a
later onset of puberty with longer CAGn and thus later activation
of the pituitary-gonadal axis [25]. Furthermore, Zitzmann et al.
[32] found that long CAGn was predictive for gynecomastia
and smaller testes, whereas KS patients with short CAGn had
more stable partnerships and professions that required higher
standards. Regarding the pharmacogenetic impact of the CAG
repeat length, different findings exist: one study reports a sup-
pression of LH, increase of haemoglobin and prostate growth in
testosterone treated KS patients with longer CAGn [32], whereas
no impact of CAGn on the effect of testosterone treatment in KS
patients was found by Bojesen et al. [33].
2.4. Skewed X-inactivation
In females, X-inactivation is random, meaning the ratio of
activation/inactivation is approximately 50%. In many studies
it was reported that the ratio of activation/inactivation in KS
patients was skewed to 80% with the preference of one allele.
The percentage of KS men with skewed X-inactivation varies
between 10 and 50% in different studies [9,18,28,34,35]. Data
regarding an impact of CAG length on the preferably inactivated
allele are contradictory: a preference of the shorter CAG allele
was reported by Zitzmann et al. [36] whereas Suzuki et al. [37]
reported a preference of the longer allele. Three studies found
no preferential allele [9,18,38].
It is possible that an abnormal or skewed inactivation in men
with a supernumerary X-chromosome could lead to reproduc-
tive or cognitive problems that are typically seen in this group
because of inadequate inactivation of the genetic material or
a selective allelic drop-out of certain X-chromosomal genes.
Nonetheless, no differences in anthropometrical, hormonal and
bone-related phenotypical features between KS patients with
skewed inactivation and those with normal inactivation were
found [18].
The different degrees of phenotypic manifestations in patients
with KS were demonstratively shown in a monozygotic twin
pair with a 46,XY/47XXY mosaicism [39]. One brother had
a hypo-gonadic phenotype with very low testosterone levels,
whereas his twin sibling had no clinical sign of hypogonadism
with normal testicular function and normal testosterone levels.
Furthermore, the height between the monozygotic twins varied,
one had normal mid-parental height, the other clearly exceeded
mid-parental height. The key factor to the phenotypic differences
 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97
Table 2
Success rates for sperm retrieval and newborns in patients with Klinefelter
syndrome using conventional TESE or micro TESE (data from [50]).
Publications Patients Success rate Liveborn
(n) children (n)
TESE
14 publications, 1997–2010 332 140 (42%) 50 (15%)
Micro TESE
8 publications, 2005–2012 409 234 (67%) 83 (20%)
of these twins is most likely the degree of mosaicism in the
different tissues, with the testicular tissue of case II showing
a lower degree mosaicism than case I. The difference in the
height, that is determined due to expression of the SHOX gene
[40], might be explained by an overexpression of the SHOX gene
in the taller brother.
3. Can men with KS be considered fertile?
Although about 8% of men with KS have sperm in their
ejaculates [8,41], paternity has been reported only in very
few cases [42–44] and until recently, KS patients were gen-
erally considered infertile. However, using ejaculated sperm
[45–47] or sperm extracted from testicular biopsies (TESE)
(e.g. [48]) and applied for direct intracytoplasmic injection
into oocytes (ICSI) pregnancy and live-born offspring could
be produced. While only few tubules in the testes display full
spermatogenesis, these can be precisely located using micro-
surgical techniques [49]. A comparison between results from
conventional TESE with micro-TESE shows that micro-TESE
is superior in terms of sperm retrieval and live-born children [50]
(Table 2).
Surprisingly, the children born show only a slightly higher
rate of sex chromosome aneuploidy compared to newborns in
general. This triggers the question how these children obtained
a regular chromosomal set while their fathers were so-called
“non-mosaic 47,XXY”. Indeed, karyotyping of sperm from
Klinefelter men showed over 95% normal haploid spermato-
zoa [51,52]. How the euploid sperm arise from the testes of a
Klinefelter man is an object of current debate. Sciurano et al.
[53] demonstrated that these sperms obviously derive from iso-
lated foci with euploid spermatogonia while somatic Sertoli
cells have a XXY constellation. They speculate that the sec-
ond X-chromosome may get lost in some spermatogonia during
ontogeny and then continue to undergo meiosis to produce X-
or Y-sperm.
Another currently discussed topic is the possible impact of
age on spermatogenesis in Klinefelter men. Some investigators
conclude from their findings that the chances of finding sperm
in testicular biopsies are higher in younger than in older patients
[54–56]. As a consequence, cryoperservation of testicular biopsy
material from pubertal boys with KS before testosterone substi-
tution is being considered for later use when paternity may be
requested [57].
91
4. Clinical and metabolic features
Men with KS exhibit marked variations in phenotype, which
may range from males with severe signs of androgen deficiency
to normally virilised males [58]. KS men are significantly taller
than normal men, but similar in height compared to other hypo-
gonadic men, while 46,XX males fall in the range of normal
women [59]. Another genetic finding contributing to height is
the polymorphism of the androgen receptor: patients with longer
CAG repeats of the AR are taller than those with short CAG
repeats [36]. These phenomena may be explained by the assump-
tion that growth controlling genes reside on the Y chromosome,
not present in women and 46,XX-males resulting in smaller
height, while lack of testosterone contributes to delayed clo-
sure of the epiphyses causing taller stature. However, the lack
of Y-linked growth genes in the 46,XX-males may cause short
stature despite low testosterone levels in the range of Klinefelter
men.
Hypogonadism itself causes an unfavourable pattern of
cytokines and adipokines, adversely altering the inflammatory
status leading to premature vascular damage and metabolic dis-
orders [60]. These mechanisms are also present in men with
KS who have an even higher metabolic risk than other hypogo-
nadal men since the incidence of diabetes type 2 is significantly
higher in KS than in other forms of hypogonadism such as
isolated hypogonadotropic hypogonadism [61]. KS is associ-
ated with significantly decreased insulin sensitivity and HDL
cholesterol levels while total fat mass and LDL cholesterol,
triglyceride, CRP and leptin are significantly increased [62].
As a consequence, the metabolic syndrome develops a com-
plex patho-physiological disorder consisting of an accumulation
of visceral adipose tissue, dyslipidemia, insulin resistance and
hypertension. Men affected by this syndrome have a fivefold
greater risk of developing type 2 diabetes mellitus and are three
times as likely to suffer a heart attack or stroke compared with
those not affected (Table 1). These risks are not restricted to men
of Caucasian origin, but have also been confirmed in patients
with KS in Japan [63] and in China [61].
Obviously, other factors than lack of testosterone must con-
tribute to this phenomenon. One of such factors could be a
generally reduced diameter of large and medium sized arteries in
KS patients as revealed by ultrasonographic investigations [64].
As this has not been reported in other forms of hypogonadism,
this could be a testosterone independent phenomenon specific
for the KS. Whether left ventricular dysfunction [65] and other
cardiovascular abnormalities [66] are related to reduced arterial
parameters remains to be investigated.
5. Psychoneurologic function
The psychological, intellectual and social development of
boys with KS may be completely normal. However, over half of
the patients develop language disorders and legasthenia, caus-
ing difficulties in communication, in learning and in school
(Table 1). In addition, memory and decision-making may be
impaired and many boys develop symptoms of autism spectrum
disorders (ASD) [67] as well mood and anxiety disorders [68].
92 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97
This leads to behavioural and social problems and isolation.
As a result, professional status and income may remain below
the family status and below the population average [69]. Social
maladjustment and isolation may also explain the higher rate
of criminal offences among men with KS, especially concern-
ing arson, sexual abuse and exhibitionism [70]. Furthermore,
among 1205 prepubertal boys referred for suspected fragile X-
syndrome because of mental retardation of unknown aetiology,
eight patients with KS were discovered [71].
Neuroimaging studies have revealed anomalies in the brain
structures of boys and adults with KS, which correlated with
psychosocial problems. “There are increases in the grey mat-
ter volume of the sensorimotor and parieto-occipital regions, as
well as significant reductions in amygdala, hippocampal, insular,
temporal and inferior-frontal grey matter volumes. Widespread
white matter abnormalities have been revealed, with reductions
in some areas (including anterior cingulated, bilaterally) but
increases in others (such as left parietal lobe)” [72]. These alter-
ations may be caused by excessive expression of genes that lie
in the pseudo-autosomal regions of the X-chromosome. These
genes have homologies on the Y-chromosome, therefore in KS
there are effectively three copies. The genes in this region are
not subjected to X-inactivation although other regions of the X-
chromosome will be subjected to X-inactivation as in normal
females. Alternatively, there is evidence that up to 15% of other
genes on the “inactivated” X-chromosome usually escape inac-
tivation in normal females. They could therefore be expressed in
excess in KS relative to typical men, but may not be expressed
to the same extent as in typical 46,XX women [12,72].
6. Testosterone treatment
Patients with KS eventually need to be substituted with
testosterone. Testosterone treatment is usually started when the
levels fall below the normal range for adult males, mostly
occurring in the middle of the third decade of life. Accord-
ing to clinical practice and current guidelines on treatment of
hypogonadism substitution can be performed with injectable
testosterone esters or transdermal testosterone gels for long-term
substitution or, on a more temporary basis, by oral testosterone
undecanoate capsules [73–75]. Since testosterone substitu-
tion has been administered since the KS was first described
and long before the criteria of evidence-based medicine were
introduced, no controlled trials have been performed aiming at
identifying the most appropriate testosterone preparation and
optimal dosing. Effects were evaluated by patients’ reports,
clinical observation and laboratory findings. The clinical impres-
sion prevailed that testosterone substitution would alleviate
most symptoms such as decreased libido, erectile dysfunction,
anaemia, osteoporosis, lumbago, depression, language abilities
and social maladjustment. Autoimmune diseases [76,77] and leg
ulcers [78] were found to improve under testosterone treatment.
Numerous further uncontrolled studies and case reports confirm
this impression. However, the patient and the empathic physi-
cian notice that this substitution is not optimal and does not fully
normalise the patient’s life.
Only recently, more critical attention has been paid to the clin-
ical outcome of testosterone substitution. For example, despite
standard testosterone substitution, quality of life in Klinefelter
patients has been found to be below the average of the gen-
eral population [79]. Bone mineral density was found lower in
adult Klinefelter patients than in age-matched controls despite
testosterone substitution [33], while other studies confirm the
beneficial effects of long-term testosterone substitution on bone
health [80]. The increased height in males with KS (see above)
may not be due to testosterone deficiency as has always been
assumed and thus considered a marker of hypogonadism, but
rather may be a consequence of an extra dosage of SHOX, an X
chromosomal and Y chromosomal gene that may escape X chro-
mosomal inactivation [81]. Similar to the role of the androgen
receptor polymorphism in the development of the KS phenotype,
the CAG repeat length also plays a modifying role in the bio-
logical effects of testosterone treatment [82,83]. Clearly, further
controlled clinical trials are needed to fully assess the benefits
of testosterone substitution and optimized treatment regimens.
Another very topical question is when and how testosterone
treatment should be started. There were early observations that
KS boys were better adjusted and had improved cognitive and
learning abilities when they were substituted from early puberty
onwards [84]. However, this never became a generally accepted
concept and only recently has this question been taken up again
in clinical trials (e.g. [85,86]), some of which are currently
ongoing. It is also difficult for the endocrinologist to convince
psychiatrists and social workers of the potential usefulness of
this hormone in adjusting the possibly criminal adolescent to his
environment when testosterone was considered an agent caus-
ing aggression and overlooking its real function in socialisation
(e.g. [87]).
Taking into consideration that there may already be a testos-
terone deficiency before puberty in KS boys, some investigations
even propagate testosterone substitution during infancy. In a ret-
rospective study comparing 34 47,XXY-boys who had received
short courses of testosterone treatment at ages three and six
years with 67 non-treated KS patients, a significant advantage
in cognitive, language, intellectual and neuromotor functions of
the treated boys was observed [88]. These encouraging find-
ings open a new dimension for testosterone substitution in KS
patients.
7. Animal models: guides to new clinical approaches
Animal models are required to explore the disturbed
genotype-phenotype correlations in addition to and beyond
possible clinical investigations. Although comparable sex-
chromosomal aberrations occur sporadically in several mam-
malian species (reviewed in [89,90]), quite generally resembling
features also observed in human pathology, the main require-
ment for an animal model is that it can be continuously
generated, that it resembles the phenotype of patients as closely
as possible and that it is practicable within a reasonable work
and cost load.
For the KS, this was particularly difficult as this sex-
chromosomal disorder is associated with male infertility–thus
 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97 93

Fig. 1. Impaired memory in a mouse model of Klinefelter syndrome. In non-conditional learning experiments, 41,XXY * mice showed an impaired memory
recognition. As a test system, the novel object task was used, which is based on the natural exploration behaviour of mice. A. In the test procedure, the animals are
firstly exposed to a blank open field arena. B. In a second round they encounter two identical objects in the open field, of which one (C) is replaced by a novel object
in the final test. The measure is the time spent in exploration of one or the other object. In mice with normal cognitive abilities, the novel object is preferred over the
known one. D. When undergoing the novel object task, 40, XY* littermate control mice showed a normal preference for the novel object exploration, whilst the 41,
XXY * males remained close to the 50% line (no preference) indicating a disturbed memory recognition (P < 0.05, unpaired Wilcoxon test, two tailed). The figure is
based on a data set from Lewejohann et al., 2009 [96].

rendering breeding of an animal model almost impossible.
However, in 1991, Eicher et al. [91] discovered a mouse line,
the B6EiLT-Y* strain, in which the males carry a mutated Y-
chromosome, the Y*. This chromosome is characterized by a
distally dislocated centromere altering chromosomal segrega-
tion during meiotic cell division and causing it to fail, in a
certain proportion and – thus – enabling the regular breeding
of male mice with a supernumerary X-chromosome [92–97].
By breeding this mouse strain, two mouse models (males with
the karyotype 41,XXY and 41,XXY *) emerged suitable for
characterising the syndrome and both were shown to resem-
ble the features of the human disorder excellently (reviewed in
[90]).
These mice have hypergonadotropic hypogonadism, are
infertile due to germ cell loss, have altered body proportions, dis-
turbed bone metabolism and exhibit cognitive and behavioural
deficits, all hallmark features of the human disorder [90,98,99].
During recent years, these models have been used in experi-
mental studies that provided important in-depth insights, some
of which had already been confirmed in clinical settings and
which have broadened understanding of the human disorder.
For example, verbal and nonverbal/spatial cognitive deficits and
neuropsychological alterations have been reported (i.e. language
disorders, reading disabilities, reviewed in [100]) but it remained
unclear to which extent these are intrinsic in genetic predisposi-
tion, due to the endocrine milieu or caused by socially enhanced
learning problems of Klinefelter boys. The mouse models
allowed experimental investigation of behavioral and cogni-
tive conditions in males with a supernumerary X-chromosome
[101] and confirmed that such males had learning deficits when
exposed to a classic pavlovian setting, in which they, although
able to fulfil the task, required much longer training than controls
[94]. In a non-conditional test (novel object task), the 41,XXY *
mice were shown to exhibit memory recognition problems [96]
(Fig. 1); moreover, social preference was also altered in the
41,XXY model [98]. Interestingly, in a study in which the set-
ting of the non-conditional testing of memory recognition, as
performed in the 41, XXY * mice, was adapted for Klinefelter
boys, the basic failure observed in mice was confirmed in these
patients [102].
94 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97
Disturbed bone metabolism, frequently observed in KS
patients, was also addressed in the mouse model. Bone volume
loss occurring in patients may be a consequence of testosterone
deficiency and therefore treatable by testosterone replacement
or may be due to other factors. 41, XXY male mice were used
to analyse bone metabolism and remodelling under androgen
treatment. It was clearly shown that testosterone deficiency
alone did not fully explain the bone phenotype as reduced bone
volume was also maintained in treated XXY mice exhibiting
normal blood testosterone levels, as in humans [18], indicat-
ing a genetic component involved in disturbed bone formation
possibly enhanced by the hypogonadal status [99].
Hypergonadotropic hypogonadism is a general feature of KS.
Disturbed Leydig cell function or maturation was suggested as
a likely reason for this endocrine phenotype, as testicular histol-
ogy of males with a supernumerary X-chromosome commonly
revealed Leydig cell hyperplasia [89]. Logically, it was proposed
that the Leydig cells of Klinefelter patients should be function-
ally disturbed and therefore responsible for the endocrine failure.
As this could not be proven in patient material, the issue was
addressed in the 41, XXY * mouse model by analysing Leydig
cells isolated from the testis. Surprisingly, when the expression
profile of those cells was examined, the cells were found to
be hyperactivated, i.e. all markers were over-expressed but no
maturation defect could be observed. Similarly, the LH receptor
was fully mature and responded to CG stimulation as expected
and the testosterone response of the cells in vitro was supe-
rior to controls. In conclusion, the Leydig cells in males with
a supernumerary X-chromosome appear to compensate as well
as possible for the disturbed milieu. This was confirmed when
intratesticular testosterone (ITT) was measured and found to be
as high as in controls [97]. Arguing from these animal find-
ings, an analysis of ITT levels in patients showed that also in
the human ITT levels are not different from healthy men [103].
This discrepancy between lowered serum testosterone and nor-
mal ITT levels remains unclear. However, recently generally
altered circulation in Klinefelter patients was reported [64] and
it was hypothesized that diminished testicular vascularization
might impede testosterone secretion. Following this hypothesis,
the testicular vessels from 41, XXY * mice were analysed – such
measurement is impossible in patient biopsies since the entire
testis has to be evaluated – and it could be confirmed that the tes-
ticular blood supply is hampered in males with a supernumerary
X-chromosome by an absolute reduction of area covered by ves-
sels and in particular by a lack of those with a larger diameter
[103].
The loss of the germ line is another general feature of the
KS, also present in both mouse models with a similar devel-
opmental pattern, i.e. being complete at the onset of puberty.
In mice, individuals with small foci of active spermatogene-
sis have been observed as seen in some patients undergoing
TESE [53,104,105] but not adequately examined. The changes
that finally result in the fading of the germ line already begin
early in development. As access to material from Klinefelter
boys is extremely limited, studies are restricted to sporadic
observational reports [106]. Investigations in the mouse model
showed that the germ line is already altered in utero and that
those germ cells maintained beyond birth undergo some kind
of euploid correction [92,93,107]. The euploidy of surviving
germ cells in focal spermatogenesis of patients was confirmed
recently and Sertoli cells – although of the XXY karyotype –
were found to support gamete maturation, which is also true in
41,XXY mice when transplanted with healthy spermatogonia
[53,95,104]. Additionally, analysis of the spermatogonial cell
population in the postnatal phase, revealed that in the testis of
41,XXY * mice expression and regulation of markers associated
with stem cell features are disturbed, indicating an impaired
stem cell potential of the spermatogonia. In sites with focal
spermatogenesis, this deregulation is rescued [105].
These data have disproven the former assumption that an-
euploid germ cells are not able to survive meiotic division and
are therefore lost. It was rather demonstrated that an intrinsic
disturbance of the germ line disables progression as long as
there is no euploid correction. Altered vascularization might
play a role as spermatogonial stem cells need close vicinity to
testicular blood vessels [108]. It might be speculated that the
testicular architecture and the endocrine phenotype are only con-
sequences of genetically driven altered circulation – a thought
which, once proven, could open novel therapeutic approaches.
Finally, there is another important advantage provided by the
mouse models. As the entire phenotype seen in KS must be due
to gene dose effects from the supernumerary X-chromosome
and as X-inactivation is not different from healthy females
[14,81,109], the candidate genes responsible must be amongst
those that escape from inactivation, the so-called escapee genes.
While in humans about 15% of the X-linked genes escape from
inactivation, in mice only 13 escapee genes are known [22] –
but these few candidates are sufficient to induce a phenotype
exactly resembling that of patients. Exploring this small num-
ber of genes in various mouse tissues revealed an unexpected
tissue- and gene-specific expression pattern, which was recently
also confirmed in a patient [23,109].
Analysis of the expression patterns of these genes will allow
important genotype-phenotype correlations as well as elucida-
tion of gene function and regulation of the basic mechanisms
behind this sex-chromosomal trisomy in the KS.
8. Conclusion and outlook
In recent years, tremendous progress has been achieved in our
understanding of the pathophysiology and the clinical manage-
ment of the KS. Foremost, the fact that a man with KS is no
longer absolutely infertile, can be considered a breakthrough.
Furthermore, it became clear that the KS is not simply a form
of hypogonadism, but that infertility and lack of testosterone
are only symptoms in a wider spectrum of other diseases and
comorbidities. Recognition of this fact by the medical profession
should contribute to enhanced diagnostic identification of this
syndrome that has often been overlooked. While the regimen
and benefits of testosterone treatment have not yet been fully
evaluated, the importance of other therapeutic modalities are
emerging, especially psychotherapeutic and behavioural sup-
port in childhood, adolescence and adulthood. These changes in
the clinical management of men with KS are based on thorough
 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97
genetic investigations, which, together with recent findings from
mouse models, will fuel further improvements for benefit of
affected patients.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
Acknowledgments
J.W. and S.W. received support from the German Research
Foundation (Deutsche Forschungsgemeinschaft, DFG grant No.
WI 2723/4-1) and M.Z. and S.W. received additional support
from the IZKF, Medical Faculty of the University of Mün-
ster (Project CRA 03/2009). The authors are grateful to Susan
Nieschlag M.A. for language editing of the manuscript and to
Maria Schalkowski for secretarial help.
References
[1] Klinefelter HF, Reifenstein EC, Albright F:. Syndrome character-
ized by gynecomastia, aspermatogenesis without A-Leydigism, and
increased excretion of follicle-stimulating hormone. J Clin Endocrinol
1942;II:615–27.
[2] Swerdlow AJ, Schoemaker MJ, Higgins CD, Wright AF, Jacobs PA,
UK Clinical Cytogenetics Group. Cancer incidence and mortality in
men with Klinefelter syndrome: a cohort study. J Natl Cancer Inst
2005;97:1204–10.
[3] Swerdlow AJ, Higgins CD, Schoemaker MJ, Wright AF, Jacobs PA,
United Kingdom Clinical Cytogenetics Group. Mortality in patients with
Klinefelter syndrome in Britain: a cohort study. J Clin Endocrinol Metab
2005;90:6516–22.
[4] Bojesen A, Juul S, Birkebaek N, Gravholt CH. Increased mortality in
Klinefelter syndrome. J Clin Endocrinol Metab 2004;89:3830–4.
[5] Bojesen A, Juul S, Birkebaek NH, Gravolt CH. Morbidity in Klinefelter
syndrome: a Danish register study based on hospital discharge diagnoses.
J Clin Endocrinol Metab 2006;91:1254–60.
[6] Bojesen A, Juul S, Gravholt CH:. Prenatal and postnatal prevalence of
Klinefelter syndrome: a national registry study. J Clin Endocrinol Metab
2003;88:622–6.
[7] Nieschlag E. Klinefelter syndrome: the commenest form of hypogo-
nadism, but often overlooked or untreated (review). Dtsch Arztebl Int
2013;110:347–53.
[8] Lanfranco F, Kamischke A, Zitzmann M, Nieschlag E. Klinefelter
syndrome: focus on reproductive functions and hormones. Lancet
2004;364:273–83.
[9] Wikström AM, Dunkel L. Klinefelter syndrome. Best Pract Res Clin
Endocrinol Metab 2011;25:239–50.
[10] Groth KA, Skakkebæk A, Høst C, Gravholt CH, Bojesen A. Clinical
review: Klinefelter syndrome – a clinical update. J Clin Endocrinol Metab
2013;98(1):20–30, http://dx.doi.org/10.1210/jc.2012-2382.
[11] Kleinheinz A, Schulze W. Klinefelter’s syndrome: new and rapid diagno-
sis by PCR analysis of XIST gene expression. Andrologia 1994;26:127–9.
[12] Vawter MP, Harvey PD, DeLisi LE. Dysregulation of X-linked gene
expression in Klinefelter’s syndrome and association with verbal cog-
nition. Am J Med Genet B Neuropsychiatr Genet 2007;144B:728–34.
[13] Stabile M, Angelino T, Caiazzo F, Olivieri P, De Marchi N, De Petro-
cellis L, et al. Fertility in a i(Xq) Klinefelter patient: importance of
XIST expression level determined by qRT-PCR in ruling out Klinefel-
ter cryptic mosaicism as cause of oligozoospermia. Mol Hum Reprod
2008;14:635–40.
95
[14] Poplinski A, Wieacker P, Kliesch S, Gromoll J. Severe XIST hypometh-
ylation clearly distinguishes (SRY+) 46,XX-maleness from Klinefelter
syndrome. Eur J Endocrinol 2010;162:169–75.
[15] Brown CJ, Hendrich BD, Rupert JL, Lafreniere RG, Xing Y, Lawrence
J, et al. The human XIST gene: analysis of a 17 kb inactive X-specific
RNA that contains conserved repeats and is highly localized within the
nucleus. Cell 1992;71:527–42.
[16] Heard E, Disteche CM. Dosage compensation in mammals: fine-tuning
the expression of the X chromosome. Genes Dev 2006;20(14):1848–67.
[17] Berletch JB, Yang F, Xu J, Carrel L, Disteche CM. Genes that escape
from X inactivation. Hum Genet 2011;130:237–45.
[18] Bojesen A, Hertz JM, Gravholt CH. Genotype and phenotype in Klinefel-
ter syndrome – impact of androgen receptor polymorphism and skewed
X inactivation. Int J Androl 2011;34:e642–8.
[19] Flaquer A, Rappold GA, Wienker TF, Fischer C. The human pseudoau-
tosomal regions: a review for genetic epidemiologists. Eur J Hum Genet
2008;16:771–9.
[20] Ross NL, Wadekar R, Lopes A, Dagnall A, Close J, Delisi LE, et al.
Methylation of two homo sapiens-specific X-Y homologous genes in
Klinefelter’s syndrome (XXY). Am J Med Genet B Neuropsychiatr Genet
2006;141B:544–8.
[21] Carrel L, Willard HF. Heterogeneous gene expression from the inactive
X chromosome: an X-linked gene that escapes X inactivation in some
human cell lines but is inactivated in others. Proc Natl Acad Sci U S A
1999;96:7364–9.
[22] Carrel L, Willard HF. X-inactivation profile reveals extensive variability
in X-linked gene expression in females. Nature 2005;434(7031):400–4.
[23] Viana J, Pidsley R, Troakes C, Spiers H, Wong CC, Al-Sarraj S, et al.
Epigenomic and transcriptomic signatures of a Klinefelter syndrome
(47,XXY) karyotype in the brain. Epigenetics 2014;9(4) [Epub ahead
of print, PubMed PMID: 24476718].
[24] Thomas NS, Hassold TJ. Aberrant recombination and the origin of Kline-
felter syndrome. Hum Reprod Update 2003;9:309–17.
[25] Wikström AM, Painter JN, Raivio T, Aittomäki K, Dunkel L. Genetic
features of the X chromosome affect pubertal development and testi-
cular degeneration in adolescent boys with Klinefelter syndrome. Clin
Endocrinol (Oxf) 2006;65:92–7.
[26] Bruining H, van Rijn S, Swaab H, Giltay J, Kates W, Kas MJ, et al. The
parent-of-origin of the extra X chromosome may differentially affect psy-
chopathology in Klinefelter syndrome. Biol Psychiatry 2010;68:1156–62.
[27] Stemkens D, Roza T, Verrij L, Swaab H, van Werkhoven MK, Alizadeh
BZ, et al. Is there an influence of X-chromosomal imprinting on the phe-
notype in Klinefelter syndrome? A clinical and molecular genetic study
of 61 cases. Clin Genet 2006;70:43–8.
[28] Ross JL, Roeltgen DP, Stefanatos G, Benecke R, Zeger MP, Kushner H,
et al. Cognitive and motor development during childhood in boys with
Klinefelter syndrome. Am J Med Genet A 2008;146A:708–19.
[29] Boks MP, de Vette MH, Sommer IE, van Rijn S, Giltay JC, Swaab H,
et al. Psychiatric morbidity and X-chromosomal origin in a Klinefelter
sample. Schizophr Res 2007;93:399–402.
[30] Choong CS, Kemppainen JA, Wilson EM. Evolution of the primate
androgen receptor: a structural basis for disease. J Mol Evol 1998;47:
334–42.
[31] 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;90:5041–6.
[32] Zitzmann M, Nieschlag E. The CAG repeat polymorphism within the
androgen receptor gene and maleness. Int J Androl 2003;26:76–83.
[33] Bojesen A, Birkebæk N, Kristensen K, Heickendorff L, Mosekilde
L, Christiansen JS, et al. Bone mineral density in Klinefelter syn-
drome is reduced and primarily determined by muscle strength and
resorptive markers, but not directly by testosterone. Osteoporos Int
2011;22:1441–50.
[34] 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.
[35] Mehta A, Malek-Jones M, Bolyakov A, Mielnik A, Schlegel PN, Paduch
DA. Methylation-specific PCR allows for fast diagnosis of X chromosome
96 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97
disomy and reveals skewed inactivation of the X chromosome in men with
Klinefelter syndrome. J Androl 2012;33:955–62.
[36] Zitzmann M, Depenbusch M, Gromoll J, Nieschlag E. 2004 X-
chromosome inactivation patterns and androgen receptor functionality
influence phenotype and social characteristics as well as pharmacoge-
netics of testosterone therapy in Klinefelter patients. J Clin Endocrinol
Metab 2004;89:6208–17.
[37] Suzuki Y, Sasagawa I, Tateno T, Ashida J, Nakada T, Muroya K, et al.
Mutation screening and CAG repeat length analysis of the androgen
receptor gene in Klinefelter’s syndrome patients with and without sper-
matogenesis. Hum Reprod 2001;16:1653–6.
[38] 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;90:5041–6.
[39] Benaiges D, Pedro-Botet J, Hernandez E, Tarragon S, Chillaron JJ, Flores
Le-Roux JA. Different clinical presentation of Klinefelter’s syndrome in
monozygotic twins. Andrologia 2014;98:20–30.
[40] Blaschke RJ, Rappold G. The pseudoautosomal regions, SHOX and dis-
ease. Curr Opin Genet Dev 2014;16:233–9.
[41] Selice R, Di Mambro A, Garolla A, Ficarra V, Iafrate M, Ferlin A,
et al. Spermatogenesis in Klinefelter syndrome. J Endocrinol Invest
2010;33:789–93.
[42] Kaplan H, Aspillaga M, Shelley TF, Gardner LI. Possible fertility in
Klinefelter’s syndrome. Lancet 1963;1:506.
[43] Laron Z, Dickerman Z, Zamir R, Galatzer A. Paternity in Klinefelter’s
syndrome – a case report. Arch Androl 1982;8:149–51.
[44] Terzoli G, Lalatta F, Lobbiani A, Simoni G, Colucci G. Fertility in a
47,XXY patient: assessment of biological paternity by deoxyribonucleic
acid fingerprinting. Fertil Steril 1992;58:821–2.
[45] Bourne H, Stern K, Clarke G, Pertile M, Speirs A, Baker HW. Delivery
of normal twins following the intracytoplasmic injection of spermato-
zoa from a patient with 47,XXY Klinefelter’s syndrome. Hum Reprod
1997;12:2447–50.
[46] Ron-el R, Friedler S, Strassburger D, Komarovsky D, Schachter M, Raziel
A. Birth of a healthy neonate following the intracytoplasmic injection of
testicular spermatozoa from a patient with Klinefelter’s syndrome. Hum
Reprod 1999;14:368–70.
[47] Crüger D, Toft B, Agerholm I, Fedder J, Hald F, Bruun-Petersen G.
Birth of a healthy girl after ICSI with ejaculated spermatozoa from a
man with non-mosaic Klinefelter’s syndrome. Hum Reprod 2001;16:
1909–11.
[48] Palermo GD, Schlegel PN, Sills ES, Veeck LL, Zaninovic N, Menendez
S, et al. Births after intracytoplasmic injection of sperm obtained by tes-
ticular extraction from men with nonmosaic Klinefelter’s syndrome. N
Engl J Med 1998;338:588–90.
[49] Schlegel PN. Nonobstructive azoospermia: a revolutionary surgical
approach and results. Semin Reprod Med 2009;27:165–70.
[50] Aksglaede L, Juul A. Testicular function and fertility in men with Kline-
felter syndrome: a review. Eur J Endocrinol 2013;168:R67–76.
[51] Rives N, Joly G, Machy A, Siméon N, Leclerc P, Macé B. Assess-
ment of sex chromosome aneuploidy in sperm nuclei from 47,XXY and
46,XY/47,XXY males: comparison with fertile and infertile males with
normal karyotype. Mol Hum Reprod 2000;6:107–12.
[52] Levron J, Aviram-Goldring A, Madgar I, Raviv G, Barkai G, Dor J. Sperm
chromosome analysis and outcome of IVF in patients with non-mosaic
Klinefelter’s syndrome. Fertil Steril 2000;74:925–9.
[53] Sciurano RB, Luna Hisano CV, Rahn MI, Brugo Olmedo S, Rey Valzacchi
G, Coco R, et al. Focal spermatogenesis originates in euploid germ cells
in classical Klinefelter patients. Hum Reprod 2009;24:2353–60.
[54] Okada H, Goda K, Yamamoto Y, et al. Age as a limiting factor for suc-
cessful sperm retrieval in patients with nonmosaic Klinefelter syndrome.
Fertil Steril 2005;84:1662–4.
[55] Bakircioglu ME, Erden HF, Kaplancan T, Ciray N, Bener F, Bahceci M.
Aging may adversely affect testicular sperm recovery in patients with
Klinefelter syndrome. Urology 2006;68:1082–6.
[56] Van Saen D, Gies I, De Schepper J, Tournaye H, Goossens E. Can pubertal
boys with Klinefelter syndrome benefit from spermatogonial stem cell
banking? Hum Reprod 2012;27:323–30.
[57] Gies I, De Schepper J, Goossens E, Van Saen D, Pennings G, Tournaye H.
Spermatogonial stem cell preservation in boys with Klinefelter syndrome:
to bank or not to bank, that’s the question. Fertil Steril 2012;98:284–9.
[58] Kamischke A, Baumgardt A, Horst J, Nieschlag E. Clinical and diag-
nostic features of patients with suspected Klinefelter syndrome. J Androl
2003;24:41–8.
[59] 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.
[60] Zitzmann M, Nieschlag E. Testosterone and the metabolic syndrome in
men: current knowledge. J Reprod Med Endocr 2006;5:1–5.
[61] Jiang-Feng M, Hong-Li X, Xue-Yan W, Min N, Shuang-Yu L, Hong-
Ding X, et al. Prevalence and risk factors of diabetes in patients with
Klinefelter syndrome: a longitudinal observational study. Fertil Steril
2012;98:1331–5.
[62] Bojesen A, Kristensen K, Birkebaek NH, Fedder J, Mosekilde L, Bennett
P, et al. The metabolic syndrome is frequent in Klinefelter’s syndrome
and is associated with abdominal obesity and hypogonadism. Diabetes
Care 2006;29:1591–8.
[63] Ishikawa T, Yamaguchi K, Kondo Y, Takenaka A, Fujisawa M.
Metabolic syndrome in men with Klinefelter’s syndrome. Urology
2008;71:1109–13.
[64] Foresta C, Caretta N, Palego P, Ferlin A, Zuccarello D, Lenzi A,
et al. Reduced artery diameters in Klinefelter syndrome. Int J Androl
2012;35(5):720–5.
[65] Andersen NH, Bojesen A, Kristensen K, Birkebaek NH, Fedder J, Bennett
P, et al. Left ventricular dysfunction in Klinefelter syndrome is associ-
ated to insulin resistance, abdominal adiposity and hypogonadism. Clin
Endocrinol (Oxf) 2008;69:785–91.
[66] Saldamarco L, Isidori AM, Marra AM, Ruvolo A, Napoli R, Bossone E,
et al. Cardiovascular abnormalities in Klinefelter syndrome. Int J Cardiol
2013;168:754–9.
[67] Bruining H, Swaab H, Kas M, van Engeland H. Psychiatric characteristics
in a self-selected sample of boys with Klinefelter syndrome. Pediatrics
2009;123:e865–70.
[68] Verri A, Cremante A, Clerici F, et al. Klinefelter’s syndrome and psy-
choneurologic function. Mol Hum Reprod 2010;16:425–33.
[69] Bojesen A, Stochholm K, Juul S, et al. Socioeconomic trajectories
affect mortality in Klinefelter syndrome. J Clin Endocrinol Metab
2011;96:2098–104.
[70] Stochholm K, Bojesen A, Jensen AS, Juul S, Gravholt CH. Criminality
in men with Klinefelter’s syndrome and XYY syndrome: a cohort study.
BMJ Open 2012;2:e000650.
[71] Khalifa MM, Struthers JL. Klinefelter syndrome is a common cause for
mental retardation of unknown etiology among prepubertal males. Clin
Genet 2002;61:49–53.
[72] Savic I. Advances in research on the neurological and neuropsychi-
atric phenotype of Klinefelter syndrome. Curr Opin Neurol 2012;25:
138–43.
[73] Nieschlag E, Behre HM. Clinical use of testosterone in hypogonadism
and other conditions. In: Nieschlag E, Behre HM, editors. (Hsgb.):
testosterone: action, deficiency, substitution. 4th edition. Cambridge:
Cambridge University Press; 2012. p. 292–308.
[74] Behre HM, Nieschlag E. Testosterone preparations for clinical use in
males. In: Nieschlag E, Behre HM, editors. Testosterone: action, defi-
ciency, substitution. 4th edition. Cambridge: University Press Cambridge;
2012. p. 309–35.
[75] Swerdloff RS, Wang CCL. Review of guidelines on diagnosis and treat-
ment of testosterone deficiency. In: Nieschlag E, Behre HM, editors.
Testosterone: action, deficiency, substitution. 4th edition. Cambridge:
Cambridge University Press; 2012. p. 408–20.
[76] Bizzaro A, Valentini G, Di Martino TG, Daponte A, De Bellis A, Iacono G.
Influence of testosterone therapy on clinical and immunological features
of autoimmune diseases associated with Klinefelter’s syndrome. J Clin
Endocrinol Metab 1987;64:32–6.
[77] Koçar IH, Yesilova Z, Ozata M, Turan M, Sengül A, Ozdemir I.
The effect of testosterone replacement treatment on immunological
 E. Nieschlag et al. / Annales d’Endocrinologie 75 (2014) 88–97
features of patients with Klinefelter’s syndrome. Clin Exp Immunol
2000;121:448–52.
[78] De Morentin HM, Dodiuk-Gad RP, Brenner S. Klinefelter’s syndrome
presenting with leg ulcers. Skinmed 2004;3:274–8.
[79] de Ronde W, de Haan A, Drent ML. Quality of life is reduced in
patients with Klinefelter syndrome on androgen replacement therapy. Eur
J Endocrinol 2009;160:465–8.
[80] Haider A, Meergans U, Traish A, Saad F, Doros G, Lips P, et al. Progres-
sive improvement of T-scores in men with osteoporosis and subnormal
serum testosterone levels upon treatment with testosterone over six years.
Int J Endocrinol 2014:ID 496948, doi:org/10.1155/2014/496948.
[81] Tüttelmann F, Gromoll J. Novel genetic aspects of Klinefelter’s
syndrome. Mol Hum Reprod 2010;16(6):386–95, http://dx.doi.org/10.
1093/molehr/gaq019.
[82] Zitzmann M, Nieschlag E. Androgen receptor gene CAG repeat length
and body mass index modulate the safety of long-term intramuscular
testosterone undecanoate therapy in hypogonadal men. J Clin Endocrinol
Metab 2007;92:3844–53.
[83] Stanworth RD, Akhtar S, Channer KS, Jones TH. The role of androgen
receptor CAG repeat polymorphism and other factors which affect the
clinical response to testosterone replacement in metabolic syndrome and
type 2 diabetes: TIMES2 sub-study. Eur J Endocrinol 2013;170:193–200.
[84] Nielsen J, Pelsen B, Sørensen K. Follow-up of 30 Klinefelter males treated
with testosterone. Clin Genet 1988;33:262–9.
[85] Rogol AD, Tartaglia N:. Considerations for androgen therapy in children
and adolescents with Klinefelter syndrome (47,XXY). Pediatr Endocrinol
Rev 2010;8(Suppl. 1):145–50.
[86] Rogol AD, Swerdloff RS, Reiter EO, Ross JL, ZumBrunnen TL, Pratt
GA, et al. A multicenter, open-label, observational study of testosterone
gel (1%) in the treatment of adolescent boys with Klinefelter syndrome
or anorchia. J Adolesc Health 2014;54:20–5.
[87] Braunisch S. Deliktprävention durch ambulante kriminaltherapeutis-
che Behandlung des Forensik-Ambulatoriums des Forensisch-Psychiatri-
schen Dienstes der Universität Bern. Schweizerische Zeitschrift für Krim-
inologie 2011;2:4–8.
[88] Samango-Sprouse CA, Sadeghin T, Mitchell FL, Dixon T, Stapleton E,
Kingery M, et al. Positive effects of short course androgen therapy on the
neurodevelopmental outcome in boys with 47,XXY syndrome at 36 and
72 months of age. Am J Med Genet A 2013;161A:501–8.
[89] Wistuba J. Animal models for Klinefelter’s syndrome and their relevance
for the clinic. Mol Hum Reprod 2010;16:375–85.
[90] Wistuba J, Werler S, Lewejohann L. Mouse models for the exploration
of Klinefelter’s syndrome. In: Conn MJ, editor. Animal models of human
diseases. London UK, Waltham USA, San Diego USA: Elsevier; 2013.
p. 759–84, http://dx.doi.org/10.1016/B978-0-415894-8.00031-2.
[91] Eicher EM, Hale DW, Hunt PA, Lee BK, Tucker PK, King TR, et al. The
mouse Y* chromosome involves a complex rearrangement, including
interstitial positioning of the pseudoautosomal region. Cytogenet Cell
Genet 1991;57(4):221–30.
[92] Mroz K, Carrel L, Hunt PA. Germ cell development in the XXY mouse:
evidence that X chromosome reactivation is independent of sexual differ-
entiation. Dev Biol 1999;207(1):229–38.
[93] Mroz K, Hassold TJ, Hunt PA. Meiotic aneuploidy in the XXY mouse:
evidence that a compromised testicular environment increases the inci-
dence of meiotic errors b. Hum Reprod 1999;14(5):151–6.
[94] Lue Y, Jentsch JD, Wang C, Rao PN, Hikim AP, Salameh W, et al. XXY
mice exhibit gonadal and behavioral phenotypes similar to Klinefelter
syndrome. Endocrinology 2005;146:4148–54.
[95] Lue Y, Liu PY, Erkkila K, Ma K, Schwarcz M, Wang C, et al. Transplanted
XY germ cells produce spermatozoa in testes of XXY mice. Int J Androl
2010;33:581–7.
97
[96] Lewejohann L, Damm O, Luetjens CM, Hämäläinen T, Simoni M,
Nieschlag E, et al. Impaired recognition memory in male mice with a
supernumerary X chromosome. Physiol Behav 2009;96:23–9.
[97] Wistuba J, Luetjens CM, Dittmann M, Werler S, Poplinski A, Damm
O, et al. Male 41,XXY* mice as a model for Klinefelter syn-
drome: hyperactivation of Leydig cells. Endocrinology 2010;151:
2898–910.
[98] Liu PY, Erkkila K, Lue Y, Jentsch JD, Schwarcz MD, Abuyounes D,
et al. Genetic, hormonal, and metabolomic influences on social behav-
ior and sex preference of XXY mice. Am J Physiol Endocrinol Metab
2010;299(3):E446–55.
[99] Liu PY, Kalak R, Lue Y, Jia Y, Erkkila K, Zhou H, et al. Genetic and
hormonal control of bone volume, architecture, and remodeling in XXY
mice. J Bone Miner Res 2010;25(10):2148–54.
[100] Boada R, Janusz J, Hutaff-Lee C, Tartaglia N. The cognitive phenotype
in Klinefelter syndrome: a review of the literature including genetic and
hormonal factors. Dev Disabil Res Rev 2009;15:284–94.
[101] Cox KH, Bonthuis PJ, Rissman EF. Mouse model systems to study sex
chromosome genes and behavior: relevance to humans. Front Neuroen-
docrinol 2014, pii:S0091-3022(13)00074-5.
[102] Bruining H, Swaab H, de Sonneville LM, van Rijn S, van Engeland H, Kas
MJ. In search for significant cognitive features in Klinefelter syndrome
through cross-species comparison of a supernumerary X chromosome.
Genes Brain Behav 2011;10(6):658–62.
[103] Tüttelmann F, Damm OS, Luetjens CM, Baldi M, Zitzmann M, Kliesch
S, et al. Intratesticular testosterone is increased in men with Kline-
felter syndrome and may not be released into the bloodstream owing
to altered testicular vascularization – a preliminary report. Andrology
2014;2:275–81, http://dx.doi.org/10.1111/j.2047-2927.2014.00190.x.
[104] Vialard F, Bailly M, Bouazzi H, Albert M, Pont JC, Mendes V, et al. The
high frequency of sperm aneuploidy in Klinefelter patients and in nonob-
structive azoospermia is due to meiotic errors in euploid spermatocytes.
J Androl 2012;33:1352–9.
[105] Werler S, Demond H, Ehmcke J, Damm OS, Middendorff R, Gromoll
J, et al. Early loss of germ cells is associated with fading expression of
Lin28, a spermatogonial stem cell marker in the 41,XXY* mouse model
for Klinefelter syndrome. Reproduction 2014;147:253–64.
[106] Aksglaede L, Wikström AM, Rajpert-De Meyts E, Dunkel L, Skakke-
baek NE, Juul A. Natural history of seminiferous tubule degeneration in
Klinefelter syndrome. Hum Reprod Update 2006;12:39–48.
[107] Hunt PA, Worthman C, Levinson H, Stallings J, LeMaire R, Mroz K,
et al. Germ cell loss in the XXY male mouse: altered X-chromosome
dosage affects prenatal development. Mol Reprod Dev 1998;49(2),
101-1.1.
[108] Yoshida S, Sukeno M, Nabeshima Y. A vasculature-associated niche
for undifferentiated spermatogonia in the mouse testis. Science
2007;317(5845):1722–6.
[109] Werler S, Poplinski A, Gromoll J, Wistuba J. Expression of genes escap-
ing from xinactivation in the 41,XXY * mouse model for Klinefelter’s
syndrome. Acta Paediat 2011;100:885–91.
[110] Gravholt CH, Jensen AS, Høst C, Bojesen A. Body composition,
metabolic syndrome and type 2 diabetes in Klinefelter syndrome. Acta
Paediatr 2011;100:871–7.
[111] Vignozzi L, Corona G, Forti G, Jannini EA, Maggi M. Clinical and ther-
apeutic aspects of Klinefelter’s syndrome: sexual function. Mol Hum
Reprod 2010;16:418–24.
[112] Ratcliffe S. Long-term outcome in children of sex chromosome abnor-
malities. Arch Dis Child 1999;80:192–5.
[113] van Rijn S, Swaab H, Aleman A, Kahn RS. Social behavior and autism
traits in a sex chromosomal disorder: Klinefelter (47XXY) syndrome. J
Autism Dev Disord 2008;38:1634–41.