A young boy with signs of puberty
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Transcript of A young boy with signs of puberty
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