Clitoromegaly and abdominal tumour as leading signs of a mediastinal non-Hodgkin lymphoma

Pseudoclitoromegaly from acute T-cell lymphoblastic leukemia

A 7-year-old girl presented with painful genital enlargement, which was first believed to be clitoromegaly of hormonal origin. However, on the physical exam the clitoris was not visible and the prepuce and labia minora were enlarged and tender. Magnetic resonance imaging demonstrated an infiltrative abnormal signal with restricted diffusion involving the enlarged clitoris and adjacent soft tissues of the prepuce and labia minora, confirming a nonhormonal infiltrative malignancy. The same abnormal signal was present in enlarged inguinal lymph nodes, the kidneys, and an anterior mediastinal mass. The pathologic diagnosis was T-cell acute lymphoblastic leukemia.

Literature Review of Periclitoral Cysts in the Prepubertal Population

STUDY OBJECTIVE

Clitoral cysts in the pediatric population are rare conditions that require careful evaluation. In this review of the literature we discuss the evaluation of clitoral abnormalities in the pediatric population, the development of clitoral cysts, and how to differentiate benign from malignant tumors. In addition, a summary of relevant cases of clitoral tumors in the literature are discussed.

DESIGN

Literature review.

DATA SOURCE

A MedLine and advanced PubMed search was conducted of all English language articles published using the search terms "clitoris" and "cyst" until February 2015. Reference tracing was completed for all articles for completeness.

MAIN OUTCOME

Literature review of clitoral cysts in the prepubertal population.

RESULTS

In total, we found 15 cases of benign, spontaneously forming clitoral cysts reported. Eleven of those cases document symptom onset before puberty. Reports of other benign clitoral lesions in the pediatric population include 1 angiokeratoma, 1 hemangiopericytoma, 1 granular cell tumor, 6 hemangiomas, and approximately 30 neurofibromas. Clitoral malignancies in the pediatric population are even more rare with only 3 cases of clitoral schwannomas, 2 rhabdomyosarcomas, 1 lymphoma, and 1 endodermal sinus tumor documented in the literature.

CONCLUSION

Clitoral cysts must be considered as a possible cause of clitoral enlargement in the prepubertal population. Clitoral tumors are distinguished clinically from hormonal abnormalities and intersex disorders by their hormonal profile, and the presence of an underlying mass. Ultrasound and magnetic resonance imaging might be useful imaging modalities to further characterize the clitoral enlargement. When confirmed as the most likely diagnosis, surgical resection is the mainstay of treatment for clitoral cysts.

Isolated transient neonatal clitoromegaly with hyperandrogenism of unknown etiology

BACKGROUND

Neonatal clitoromegaly is usually attributed to androgen stimulation secondary to congenital adrenal hyperplasia or in utero androgen exposure. We present a unique case of transient, isolated neonatal clitoromegaly, associated with increased androgen levels of unidentifiable cause, which spontaneously resolved when the androgen levels normalized. This is the first report where, despite an exhaustive workup, the cause of hyperandrogenism remains unknown.

CASE

A female infant was delivered at 25 + 5 weeks gestational age. Clitoromegaly was first documented at 3 months of age (18 mm long, |13 mm wide). There was no other evidence of virilization. There was no neonatal history of transfusions or androgen-medication exposure. Initial bloodwork documented extremely high levels of free testosterone (117 pmol/L) and dehydroepiandrosterone sulfate (DHEAS). Further tests ruled out the following diagnoses: 21-hydroxylase deficiency, 11-betahydroxylase deficiency, testicular feminization, presence of ovotesticular tissue, and androgen-secreting tumors. Maternal history ruled out in utero androgen exposure, maternal drug use, hyperandrogenism, or virilization during pregnancy, and antenatal imaging had not detected a maternal ovarian mass or adrenal tumor. The infant's androgen levels spontaneously declined, and by 4 months of age had normalized without therapy (free testosterone 8 pmol/L). At 5 months of age, the clitoral measurements normalized (10mm long, 5mm wide).

CONCLUSION

In this case of a premature female infant, hyperandrogenism and clitoromegaly resolved spontaneously. Only 1 other case of hyperandrogenism and clitoromegaly that resolved spontaneously in a preterm infant has been reported. In that case, the clitoromegaly and high testosterone levels were attributed to repeated blood transfusions from an adult male. The etiology of the hyperandrogenism and resultant clitoromegaly in our case is not known.