Delayed diagnosis and false relapse due to paternal testosterone use in adrenocortical carcinoma

Cyclophosphamide Toxicity in Pediatric Nephrotic Syndrome Patient: A Case Report and Literature Review

BACKGROUND

Primary membranous nephropathy is a rare presentation in children. Patients unresponsive to steroids and experiencing frequent relapse are considered steroid-resistant. They often require complex treatment regimens consisting of immunosuppressants like cyclophosphamide, tacrolimus, and cyclosporin A.

CASE

In the present case, a 5-year-old child was suffering from steroid-resistant nephrotic syndrome for the past 10 months. He was initially treated with prednisolone 20mg but was subsequently found to be steroid-resistant. A renal biopsy revealed primary podocytopathy with immunocomplex deposits in podocyte tissues, suggesting primary membranous nephropathy as the cause of SRNS (steroid-resistant nephrotic syndrome). Cyclophosphamide 25mg twice daily was added to the treatment plan since the child did not tolerate tacrolimus therapy. During a subsequent follow-up, the physician reduced the cyclophosphamide 25mg dose to once a day, but parents misinterpreted this, and the child received a larger dose, cyclophosphamide 25mg, four times a day for 20 days. This resulted in cyclophosphamide toxicity-induced neutropenia, alopecia and posing the child at greater risk of sepsis.

CONCLUSION

Nephrotic syndrome is a chronic disease that demands extensive treatment plans and strict monitoring. Medication errors are common among parents or caregivers of pediatric patients. This case is a take-home message emphasizing the significance of patient-centered communication in preventing medication errors. A clinical pharmacist can aid in conveying simple and unambiguous information to parents or caregivers.

Adrenocortical carcinoma in a 10-month-old infant: A literature review and a rare case report

Adrenocortical carcinoma (ACC) in children is a rare condition. The annual incidence of ACC is extremely low, with only 0.2-0.3 cases per million children. The clinical presentations of ACC are numerous, such as terminal hair appearance, pubertal progress, hypercortisolism, enlarged clitoris, acne, systemic arterial hypertension, weight gain, and voice change.

Case presentation

A 10-month-old female infant presented by her parents to the Department of Endocrinology with a mass on the right adrenal gland and Cushing's syndrome symptoms. Surgery was performed. The death occurred after two times resuscitation due to sudden cardiac arrest.

Clinical discussion

The adrenal gland consists of two distinct parts. Different types of tumors arise from each part of the adrenal gland. The most common tumor in adrenomedullary tumors was neuroblastoma which accounted for 60.4% of adrenal tumors. ACC in children is a rare condition. The etiology of ACTs is unclear.

Conclusion

This case emphasizes that early diagnosis has a considerable role in preventing major complications. Also to advise considering ACC as a differential diagnosis when similar symptoms are found in an infant.

Precocious sexual development in a male toddler caused by unrecognized transdermal exposure to testosterone: case report and review of the literature

OBJECTIVES

Exogenous exposure to transdermal testosterone is often overlooked as a cause of precocious sexual development in children.

CASE PRESENTATION

A 16-month-old male presented for a second opinion consultation before commencing treatment with bicalutamide and anastrozole for a presumptive diagnosis of familial gonadotropin-independent male-limited sexual precocity. Enlargement of the penis was first observed at four months of age. The initial evaluation showed isolated elevation of his plasma testosterone level; however, by 16 months, his testosterone level was prepubertal and no pathogenic variants in the LHC GR gene were identified. The history revealed that his grandfather, who had cared for him regularly in the first year of life, had used testosterone gel for treatment of hypogonadism.

CONCLUSIONS

Despite the 2009 "black box" warning issued by the United States Food and Drug Administration (FDA) regarding potential consequences of transdermal testosterone exposure to women and children, this continues to be an important cause of sexual precocity in children. Children are often subjected to unnecessary and costly evaluation before this exposure is recognized, underscoring the importance of obtaining a thorough medical, family, and social history tailored to the differential diagnosis.

Premature Pubarche due to Exogenous Testosterone Gel or Intense Diaper Rash Prevention Cream Use: A Case Series

BACKGROUND/AIMS

Premature pubarche is associated with conditions such as virilizing congenital adrenal hyperplasia, androgen-secreting tumors, and exogenous exposure to androgen products. We describe the clinical and hormonal features of a series of children who were referred to endocrine evaluation due to premature pubarche.

METHODS

This is a retrospective case series study of 14 children with premature pubarche and/or virilization. Five were unintentionally exposed to testosterone gel (parental use). Nine patients were intensely exposed to diaper rash prevention creams. Clinical and laboratory data were revised.

RESULTS

Moderate to severe virilization was detected in the 5 patients (2 boys and 3 girls) who were exposed to testosterone gel. These patients had pubic hair development associated with clitoromegaly (3/3), penile enlargement (2/2), and accelerated growth (5/5). Testosterone levels were elevated in 4/5 patients associated with normal prepubertal gonadotropin levels and adrenal androgen precursors. The 9 children who were intensely exposed to diaper rash prevention creams had mild pubarche (intermediate hair) without any other clinical manifestation of pubertal development. Three of them exhibited pubic hair thinning after cream withdrawal.

CONCLUSION

Unintentional topical androgen exposure or the intense use of diaper rash prevention cream should be ruled out in children with precocious pubarche and/or virilization signs to avoid misdiagnosis and expendable investigation.

Pubertal outcome in a female with virilizing adrenocortical carcinoma

Adrenocortical tumors are neoplasms that rarely occur in pediatric patients. Adrenocortical carcinoma (ACC) is even more uncommon, and is an aggressive malignancy with 5-year survival of 55% in a registry series. There is a lack of information on long-term endocrine outcome in survivors. We describe a 10-year follow-up in a patient who presented at 3 years 5 months with a 1-year history of axillary odor and 6 months' history of pubic hair development with an increased clitoral size. Androgen levels were increased and a pelvic sonogram revealed a suprarenal mass of the left kidney. The tumor was successfully removed. At 6 years 11 months, androgen levels increased again. Workup for tumor recurrence was negative and the findings likely represented early adrenarche. The patient had menarche at an appropriate time and attained a height appropriate for her family.