A boy with precocious puberty

Dr. Mashfiqul HasanResident, MD Phase A (EM)

Discipline of Endocrine MedicineBSMMU

Case summary Short discussion

Overview

Case summary

7 year Boy Only child of parents

Particulars

Appearance of pubic hair, facial hair Gradual enlargement of phallus Deepening of the voice

For 5-6 months

Presenting problems

No history of headache, visual disturbance or seizure.

No significant past illness, no regular medication. No history of early onset puberty in family.

Other history

Physical findings Pubic hair :

Slightly curled, dark, coarse, spread sparsely.

Tanner stage of pubic hair: P3

Physical findings Testis: 15 ml on

both sides, firm, symmetrical, smooth surface

Stretched penile length: 12.5 cm

Tanner stage of genitalia: G4

Height: 143 cm

Current height : 143 cm Father’s height : 158 cm Mother’s height : 151 cm Expected adult height:

So, the expected adult height is : ◦ ` 161 cm (±10cm)

The target height

Investigations

Accelerated (>1 year)

Bone age

S. Testosterone 4.9 nmol/L(0.1-1.0 nmol/l for 6-9 years)

S. LH 2.27 IU/L(0.01-0.78 nmol/l for 8-10 years)

S. FSH 3.26 IU/L(0.2–1.67 IU/L for 8-9 years)

Hormones

LH spike (>10 mIU/ml) after 30 minutes.

GnRH stimulation test

No significant abnormality.

MRI of brain

Central idiopathic precocious puberty

Diagnosis

Inj. Decapeptyl (11.25 mg) 3 monthly Plan is to continue up to 11 years of age Now he is on regular follow up

Treatment

Discussion

Pulsatile secretion of gonadotropin-releasing hormone (GnRH) and activation of the hypothalamo–pituitary–gonadal axis

Lower end of the normal range for the onset of puberty: ◦ 8 years in girls and ◦ 9 years 6 months in boys

Puberty

Classification of precocious puberty

Central or Gonadotropin dependent

Peripheral or Gonadotropin independent

Short adult stature due to early epiphyseal fusion,

Underlying pathology Adverse psychosocial outcomes

Physical & psychosocial problem

Potential for progression

Evaluation of mechanism

50% of cases regress or stop progressing, and no treatment is necessary

Evaluation is needed when◦Progression through pubertal stages◦Growth velocity ◦Bone age ◦LH peak after GnRH agonist

Progression of puberty

Clinical Lab investigations

◦

Evaluation

Family history Features of CNS lesion Testicular size Features of specific cause

Clinical evaluation

S. Testosterone/S. Estradiol S. LH, S. FSH GnRH stimulation test S. ß-hCG S. DHEAS S. 17-hydroxy Progesterone Thyroid function test

Lab evaluation

Pelvic ultrasound Testicular ultrasound MRI of brain

Imaging

Management

GnRH agonists◦Triptorelin (Decapeptyl)

Management of CNS lesion

Central precocious puberty

Removal of the cause

Peripheral precocious puberty

Social stigmata, psychosocial impact

Clinical dilemma Rational approach

Take home message

Acknowledgement

THANK YOU