Presentation and Care for Children with Peripheral Precocious Puberty

Peripheral precocious puberty (PPP) refers to the early onset of sexual maturation that is independent of central nervous system control. The extensive differential diagnosis includes congenital and acquired causes. Presenting features depend on which class of sex steroids is involved, and diagnosis rests on hormonal and, if indicated, imaging and/or genetic studies. Effective treatment exists for nearly all causes of PPP. Ongoing research will advance our therapeutic armamentarium and understanding of the pathophysiologic basis of these conditions.

Diagnosis of Central Precocious Puberty

A thorough history and physical examination including Tanner staging and growth assessments can guide differential diagnosis and aid in the evaluation of precocious puberty. Basal luteinizing hormone levels measured using a highly sensitive assay can be helpful in diagnosing central precocious puberty (CPP). Brain MRI is indicated with males diagnosed with CPP and females under the age of 6 with CPP. As more information becomes available regarding the genetic etiologies of CPP, genetic testing may preclude the need for imaging studies and other hormonal testing, especially in familial cases.

Vaginal bleeding imitated rape in a 6-year old girl, a case report about granulosa cell tumor as a reason of peripheral precocious puberty

INTRODUCTION

Although female victims of sexual child abuse present with symptoms such as local pain and vaginal bleeding, however, before any definitive diagnosis a comprehensive physical examination along with a detailed history related to vaginal bleeding should be taken from the patient. Undoubtedly, we must not forget that only one of the causes of vaginal bleeding is rape. Therefore, before making a final diagnosis, other causes of this symptom must be carefully examined.

CASE PRESENTATION

The patient was a 6-years-old female who was hospitalized for notable generalized abdominal distention, acute lower abdomen pain associated with nausea and mild fever lasting 5 days progressively worsening, thelarche and vaginal bleeding. Ultrasound examination showed that multilocular-solid masses located in right side of abdomen which led to surgery and mass excision. Histopathology diagnosis was a juvenile granulosa cell tumor of the ovary.

DISCUSSION

Among the various causes of peripheral premature puberty, granulosa cell tumor (GCT) is rare but very important. Since in the two age groups - prepuberty and menopause - we don't expect to see vaginal bleeding, the occurrence of this disorder especially in association with breast enlargement in prepubertal group, need to appropriate imaging including pelvic ultrasound and bone age determination also laboratory data such as level of sex hormones and tumor markers to avoid misdiagnosis.

CONCLUSION

We report the case of a granulosa cell tumor patient with vaginal bleeding that a complete history and examination provides the right path to a diagnosis.

Peripheral precocious puberty in Li-Fraumeni syndrome: a case report and literature review of pure androgen-secreting adrenocortical tumors

INTRODUCTION

Pure androgen-secreting adrenocortical tumors are a rare but important cause of peripheral precocious puberty.

CASE PRESENTATION

Here, we report a pure androgen-secreting adrenocortical tumor in a 2.5-year-old boy presenting with penile enlargement, pubic hair, frequent erections, and rapid linear growth. We confirmed the diagnosis through laboratory tests, medical imaging, and histology. Furthermore, genetic testing detected a pathogenic germline variant in the TP53 gene, molecularly confirming underlying Li-Fraumeni syndrome.

DISCUSSION

Only 15 well-documented cases of pure androgen-secreting adrenocortical tumors have been reported so far. No clinical or imaging signs were identified to differentiate adenomas from carcinomas, and no other cases of Li-Fraumeni syndrome were diagnosed in the four patients that underwent genetic testing. However, diagnosing Li-Fraumeni syndrome is important as it implies a need for intensive tumor surveillance and avoidance of ionizing radiation.

CONCLUSION

In this article, we emphasize the need to screen for TP53 gene variants in children with androgen-producing adrenal adenomas and report an association with arterial hypertension.

A Case of Peripheral Precocious Puberty May Be Caused by a Diet Containing Phytosterols in a 20-Month-Old Boy

INTRODUCTION

Precocious puberty in boys generally remains an etiology. In addition to the causes of endogenous hormone changes, endocrine-disrupting chemicals of exogenous substances may interfere with children's pubertal development.

CASE PRESENTATION

A 20-month-old boy presented with peripheral precocious puberty may be due to a phytosterol-containing diet. The patient came to see a doctor because of acne, hairiness, increased penis size, and coarse voice. Genital examination revealed a Tanner stage of 2 for pubic hair and a stretched penile length of 5 cm, which disagreed with the prepubertal testicular volume (2 mL bilaterally). At the same time, he was found to have pigmentation on both nipples and areola. The concentrations of estradiol and testosterone increased significantly. Since the age of 6 months, the patient had taken food added with a large amount of chicken essence seasoning (a flavoring in Chinese cooking), with an average of 15 g of this seasoning a day. A kind of phytosterol (C29H48O) was detected in chicken essence seasoning by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS). After avoidance of the chicken essence seasoning, the patient's sex hormone levels decreased, all clinical symptoms returned to normal, and no further development of secondary sexual characteristics was detected.

CONCLUSION

This phytosterol-containing diet may be responsible for the sexual development of this patient. However, the mechanism of how phytosterols affect the process of development in children needs to be further explored.

Precocious puberty: The clinical profile and the etiological classification of children presented at a tertiary care children's hospital

Objectives

To determine the clinical spectrum and underlying etiologies of children presented with precocious puberty at The Children's Hospital &The Institute of Child health, Lahore.

Methods

It is a retrospective review of all the children presented with precocious puberty over one year, from January 2015 to December 2015; at the department of Paediatric Endocrinology & Diabetes, The Children's Hospital & The Institute of Child Health, Lahore.

Results

Total 43 cases of precocious puberty (PP), with 26 females were reported in one year. Central precocious puberty (CPP) constituted 55.8% (24/43) and was found to be more prevalent in female (22/24). In 20/24 cases (83.3%) of central precocious puberty underlying etiology was idiopathic. Peripheral precocious puberty was found in 19/43 cases (44.1%) with male predominance (15/19). Congenital adrenal hyperplasia was the most frequent (12/19) underlying cause of peripheral precocious puberty in our cohort.

Conclusion

Precocious puberty could be a manifestation of underlying serious medical condition. It should be thoroughly evaluated with the aim to diagnose the underlying pathology and to treat them promptly.

Peripheral precocious puberty in a girl with an intracranial hCG-producing tumor: case report and literature review

Human chorionic gonadotropin (hCG)-producing tumors cause peripheral precocious puberty (PP) in boys, but generally not in girls. Homology between LH and hCG activates the LH receptor in testicular Leydig cells, increases testosterone production, and causes virilization. However, since FSH action is required for follicle development, hCG action alone does not increase estradiol (E2) production and does not cause feminization. Only a few cases of peripheral PP with hCG tumors in girls have been reported. We describe the case of a 7-year-old Japanese girl with peripheral PP associated with an hCG-producing tumor. She had prolonged vomiting, loss of appetite, and Tanner stage III breast development. Although no apparent increase in growth rate, bone age was advanced at 9.8 years. Serum E2 was slightly elevated and LH and FSH were below the measurement sensitivity, and abdominal ultrasonography and computed tomography images showed no abnormal findings in the uterus or ovaries. Subsequently, she developed visual field disturbance and loss of consciousness, and brain magnetic resonance imaging revealed an intracranial tumor. Based on pathological findings and abnormally high serum hCG-β level (48,800 IU/L), intracranial choriocarcinoma was diagnosed. 2.5 months after the start of chemotherapy, the hCG-β level became almost negative and the breast development disappeared synchronously. Tissue immunostaining of the tumor showed strong positivity for aromatase and hCG, indicating that the choriocarcinoma cells themselves may have produced estrogen via aromatase. This unique case highlights the possibility that hCG-producing tumors can cause peripheral PP in girls as well as boys.

Diagnosis and management of precocious sexual maturation: an updated review

The classic definition of precocious sexual maturation is the development of secondary sexual characteristics before 8 years of age in girls and before 9 years of age in boys. It is classified as central precocious puberty when premature maturation of the hypothalamic-pituitary-gonadal axis occurs, and as peripheral precocious puberty when there is excessive secretion of sex hormones, independent of gonadotropin secretion. Precocious sexual maturation is more common in girls, generally central precocious puberty of idiopathic origin. In boys, it tends to be linked to central nervous system abnormalities. Clinical evaluation should include a detailed history and physical examination, including anthropometric measurements, calculation of growth velocity, and evaluation of secondary sexual characteristics. The main sign to suspect the onset of puberty is breast tissue development (thelarche) in girls and testicular enlargement (≥4 mL) in boys. Hormonal assessment and imaging are required for diagnosis and identification of the etiology. Genetic testing should be considered if there is a family history of precocious puberty or other clinical features suggestive of a genetic syndrome. Long-acting gonadotropin-releasing hormone analogs are the standard of care for central precocious puberty management, while peripheral precocious puberty management depends on the etiology.Conclusion: The aim of this review is to address the epidemiology, etiology, clinical assessment, and management of precocious sexual maturation. What is Known: • The main sign to suspect the onset of puberty is breast tissue development (thelarche) in girls and testicular enlargement (≥4 mL) in boys. The classic definition of precocious sexual maturation is the development of secondary sexual characteristics before 8 years of age in girls and before 9 years of age in boys. • Long-acting gonadotropin-releasing hormone agonist (GnRHa) is the standard of care for CPP management, and adequate hormone suppression results in the stabilization of pubertal progression, a decline in growth velocity, and a decrease in bone age advancement. What is New: • Most cases of precocious sexual maturation are gonadotropin-dependent and currently assumed to be idiopathic, but mutations in genes involved in pubertal development have been identified, such as MKRN3 and DLK1. • A different preparation of long-acting GnRHa is now available: 6-month subcutaneous injection.

Delayed and Precocious Puberty: Genetic Underpinnings and Treatments

Delayed puberty may signify a common variation of normal development, or indicate the presence of a pathologic process. Constitutional delay of growth and puberty is a strongly familial type of developmental pattern and accounts for the vast majority of children who are "late bloomers." Individuals with sex chromosomal abnormalities frequently have hypergonadotropic hypogonadism. There are currently 4 known monogenic causes of central precocious puberty. The primary treatment goal in children with hypogonadism is to mimic normal pubertal progression, while the primary aims for the management of precocious puberty are preservation of height potential and prevention of further pubertal development.

Disorders of Pubertal Onset

Evaluation of the child with abnormal pubertal development can be challenging for the primary care provider. Understanding the factors associated with timing of pubertal onset and the normal sequence of pubertal changes is useful in evaluation of children with puberty disorders. A thorough workup includes assessment of growth rate, Tanner staging, and rate of pubertal progression, in addition to an extensive history and physical examination to identify signs and symptoms of disorders associated with abnormal pubertal timing. Initial diagnostic studies will most often include a bone age, levels of gonadotropins, and levels of estradiol (for girls) or testosterone (for boys).

Phenotypic testicular abnormalities and pubertal development in boys with McCune-Albright syndrome

Aim of this survey is to review the few available literature data on pathophysiologic and clinical aspects of pubertal development in boys with McCune-Albright syndrome (MAS). On the basis of such analysis, we concluded that:

1) peripheral precocious puberty (PPP) is significantly more infrequent in boys than in girls; 2) the most common testicular abnormality at MAS presentation is macroorchidism, that may be either monolateral or bilateral; 3) macroorchidism is not always associated with clinical and biochemical evidence of PPP; 4) testicular microlothiasis is distinctly more frequent in boys with MAS than in those without MAS; 5) the available therapeutic schedules have to be adopted already at MAS presentation only in the cases with PPP.

Central Precocious Puberty Secondary to Adrenocortical Adenoma in a Female Child: Case Report and Review of the Literature

BACKGROUND

Pediatric adrenocortical tumors are rare but significant causes of virilization and peripheral precocious puberty (PPP).

CASE

A 4-year-old girl presented with development of breast, pubic hair, and facial acne. Her bone age was advanced, and her gonadotropin level did not elevate in a gonadotropin-releasing hormone (GnRH) test. High levels of dehydroepiandrosterone sulfate, estradiol, and testosterone, and detection of a tumor in the left adrenal gland of the abdomen using computed tomography led to a diagnosis of PPP due to adrenal tumor. Adrenal adenoma was diagnosed with pathology after the tumor was removed. Ultrasonography detected multicystic ovaries before surgery. Although the androgen levels decreased, high estrogen levels persisted after complete tumor resection. Approximately 1 year after the surgery, the patient's breast development persisted, bone age progressed rapidly, and gonadotropin levels increased in a GnRH test. Central precocious puberty was diagnosed, and treatment with GnRH analogues was started.

SUMMARY AND CONCLUSION

Adrenal adenoma might present with isosexual PPP as well as virilization in girls. The ovaries should be carefully assessed in these patients. Prolonged exposure to androgen and estrogen might cause ovarian multicysts leading to persistence of high estrogen levels and initiation of central precocious puberty.

Peripheral Precocious Puberty due to Functioning Adrenocortical Tumor: Description of Two Cases

BACKGROUND

Adrenocortical tumors (ACTs) represent less than 0.2% of all childhood neoplasms. Frequent clinical manifestations are virilization, hypercortisolism, and peripheral precocious puberty (PPP).

CASES

We describe two cases in which ACTs were responsible for virilization (case 1) and PPP (case 2) in prepubertal girls. In both cases an ACT diagnosis was made after 5-6 months from the first appearance of clinical signs. Surgery was performed within 1 month of diagnosis, and the benign nature of tumors was histologically confirmed. Despite complete tumor resection, virilizing features persisted.

SUMMARY AND CONCLUSIONS

Adrenocortical tumors should be considered early in the assessment of PPP. There is often a significant delay between the onset of symptoms and accurate diagnosis but early treatment is essential to limit the clinical manifestations of androgen overproduction.

Clinical and endocrine characteristics and genetic analysis of Korean children with McCune-Albright syndrome: a retrospective cohort study

Background

McCune–Albright syndrome (MAS) is a rare disease defined by the triad of fibrous dysplasia (FD), café au lait spots, and peripheral precocious puberty (PP). Because of the rarity of this disease, only a few individuals with MAS have been reported in Korea. We describe the various clinical and endocrine manifestations and genetic analysis of 14 patients with MAS in Korea.

Methods

Patients’ clinical data—including peripheral PP, FD, and other endocrine problems—were reviewed retrospectively. In addition, treatment experiences of letrozole in five patients with peripheral PP were described. Mutant enrichment with 3′-modified oligonucleotides - polymerase chain reaction (MEMO-PCR) was performed on eight patients to detect mutation in GNAS using blood. MEMO-PCR is a simple and practical method that enables the nondestructive selection and enrichment of minor mutant alleles in blood.

Results

The median age at diagnosis was 5 years 2 months (range: 18 months to 16 years). Eleven patients were female, and three were male. Thirteen patients showed FD. All female patients showed peripheral PP at onset, and three patients subsequently developed central PP. There was a significant decrease in estradiol levels after two years of letrozole treatment. However, bone age was advanced in four patients. Two patients had clinical hyperthyroidism, and two patients had growth hormone (GH) excess with pituitary microadenoma. c.602G > A (p.Arg201His) in GNAS was detected in two patients in blood, and c.601C > T (p.Arg201Cys) in GNAS was detected in one patient in pituitary adenoma.

Conclusions

This study described the various clinical manifestations of 14 patients with MAS in a single center in Korea. This study first applied MEMO-PCR on MAS patients to detect GNAS mutation. Because a broad spectrum of endocrine manifestations could be found in MAS, multiple endocrinopathies should be monitored in MAS patients. Better treatment options for peripheral PP with MAS are needed.

Autonomous Ovarian Cysts in Prepubertal Girls. How Aggressive Should We Be? A Review of the Literature

STUDY OBJECTIVE

Precocious pseudopuberty in girls occurs as a result of peripheral estrogen production, most commonly through an autonomous ovarian cyst or in patients with McCune Albright syndrome. Current management is either conservative or surgical. The aim of this study was to identify available literature on presentation, course and treatment of such cases.

DESIGN

We performed a medline literature search using the key words 'ovarian autonomous cyst' and 'pseudopuberty'. We included articles published in English, from 1980 to date relating to females aged 2 to 8 years. We excluded papers on other endocrine conditions resulting in premature puberty.

OUTCOME MEASURES

Type of management, time of resolution, recurrence, progression to Central Precocious Puberty and McCune Albright Syndrome.

RESULTS

We identified 9 articles referring to 26 cases of autonomous ovarian cysts. All patients had suppressed LHRH testing and had simple ovarian cysts producing estradiol. Median age of patients was 5 years (range 2.2-8) and size of cyst was 41.5mm (9-60). Ten patients underwent cystectomy or oophorectomy, three were given cyproterone acetate and 13 were managed conservatively. Nine of 13 patients that were managed conservatively and two of those that had a cystectomy had a recurrence. There were three cases that progressed to central precocious puberty (CPP) and one case that was then identified to have McCune Albright (MCA) syndrome. One further case with multiple recurrences was given long term treatment with letrozole.

CONCLUSION

We conclude that although a conservative approach should always be proposed in the first instance, one should be aware of the risk of recurrence and progression to CPP or MCA. Antiestrogen treatment appears promising; however data comparing it with surgical options and particularly long term consequences with regards to future reproductive outcomes are not available.

Etiology of precocious puberty, 10 years study in Endocrine Reserch Centre (Firouzgar), Tehran

BACKGROUND

Precocious puberty, as early physical development and low final height might lead to psychosocial problems.

OBJECTIVE

To evaluate etiology and clinical feature of precocious puberty in a cohort of Iranian children.

MATERIALS AND METHODS

In this case-series study, 44 girls and 8 boys with precocious puberty referred to Endocrine Reserch Centre (Firouzgar), Institute of Endocrinology and Metabolism (Hemmat Campus), were examined in a 10 years period of time.

RESULTS

Mean age of girls and boys was 7.43±1.4 years and 5.8±2.1 years respectively. Most of the patients fell within the age category of 7-7.9 years old (40.9% for girls and 50% for boys). Patients, concerning etiology of precocious puberty were classified in three categories: 42.6% of patients had central precocious puberty (CPP), including idiopathic CPP (87.5%) and neurogenic CPP (12.5%). 23.3% of patients had peripheral precocious puberty (PPP), including congenital adrenal hyperplasia (CAH) (42.8%), ovarian cysts (28.4%), McCune-Albright syndrome (14.2%) and adrenal carcinoma (14.2%). 34.1% of girls and 25% of boys had normal variant puberty including premature thelarche (57%), premature adrenarche (38%) as well as premature menarche (4.7%l).

CONCLUSION

The most common etiology of precocious puberty in girls was idiopathic central precocious puberty and premature thelarche, while in boys they were neurogenic central precocious puberty and CAH. Therefore precocious puberty in girls is usually benign. In boys, CNS anomalies should first be considered in the differential diagnosis of CPP. Therefore brain Magnetic Resonance Imaging (MRI) is mandatory in all cases.