3 year old boy with puberty. Katie Stanley, MD August 1, 2013

Transcription

1 3 year old boy with puberty Katie Stanley, MD August 1, 2013

2 Initial presentation 3 and 11/12 year old boy with signs of puberty Presented to outside endocrinologist in 2002 with: Pubic hair since 2.5 years Acne, muscular body build, body odor, aggressive behavior since 3 years old Penile enlargement w/o testicular enlargement Accelerated growth Ht 50% 2 yo-> >97% by 3 yo

3 PMH, Family, and Social History PMH Born via csx 2/2 FTP with BW 6 lbs 15 oz, birth length 20 inches Healthy, met developmental milestones appropriately Family Hx Father 37 yo, 73 inches, 240 lbs, nl puberty Mother 36 yo, 64 inches, 114 lbs, menarche 12.5 yrs No testitoxicosis or other early puberty Social Hx LAHW with parents, 9 month old sister In preschool

4 Physical Exam T 37.1, P 66, RR 20, BP 120/54 Wt 32.3 kg (>97%, wt age 10 yrs) Ht cm (>97%, ht age 8 yrs) General: muscular build, appears older than stated age, difficulty with self-restraint HEENT: unremarkable including fundi and visual fields Neck: supple, no thyromegaly Skin: comedonal and inflammatory acne on face and upper back GU: Testes cm b/l, stretched penile length 8.5 cm, T3 pubic hair, T1 axillary hair

5 Differential Diagnosis Gonadotropin Dependent Gonadotropin Independent Leydig cell tumors HCG secreting tumors Familial male-limited precocious puberty Exogenous androgens Adrenal androgen producing tumors CAH McCune-Albright

6 Work-up Initial labs LH <0.02 FSH 0.8 Testosterone 56 ng/dl 17OH-progesterone 27 ng/dl DHEA-S 15 mcg/dl Beta-HCG<2 miu/ml Dynamic testing ACTH stimulation test Peak 17OHP 192 ng/dl, peak 17OH-preg 144 ngd/l GnRH stimulation test Peak LH 0.25, peak FSH 1.4, baseline T 114 ng/dl

7 Work-up continued Imaging Bone age years at 4 yo CT and MRI of abdomen normal Testicular ultrasound normal MRI pituitary normal Started on ketoconazole Genetic testing Mutation analysis of LH receptor exon 11

8 Transfer of Care to U of C 4 3/12 years Tanner 3 PH but decreased amount Bone age 12.7 LH<0.15, FSH <0.15, Total T 72, Free T 16, E2 37 Sleep and GnRH agonist study Arimidex added, ketoconazole lowered 4 6/12 years Increased PH, acne, difficult behavior Labs: LH <0.15, FSH 0.2, Testosterone 33, E2 32, AD<20, DHEA-S 12 Spironolactone added

9 Course continued Age Bone age PE Labs Tx 4 9/ Ht 131 cm (HA 8 7/12) GU exam LH 0.3, FSH 1.7, T 17, E2 44 Ketoconazole Spironolactone Arimidex unchanged 4 11/ cm GV 5 Testes prepubertal LH 3.4, FSH 3.0, T 63, E2 63, AD <20 Same as above What now?

10 Course continued Age Bone age PE Labs Tx 5 1/ cm GV 3 GU unchanged 5 3/ years cm GV 6.6 GU unchanged FSH 0.2, LH 0.8, T 14, E2 31 FSH 0.2, LH 0.2, T 23, E2 42 Lupron has been added Arimidex changed to Tamoxifen

11 Course continued 5 and 9/12 years LH 0.7, FSH 0.3, T 38, E2 52 FSH and LH receptors of pt and parents sequenced A key piece of history Age Bone age PE Labs Tx 6 8/ at 6 2/ cm GV 4.5 Testes 1.6 T2 PH LH 0.6, FSH 0.4, T <10, E2 34 Ketoconazole Spironolactone Tamoxifen Lupron 7 2/ cm GV 2.8 Testes 1.7 Early T3 PH FSH 0.5, LH 0.5, T <10, E2 42 Same as above

12 Is it time to go through puberty yet? Age Bone age PE Labs Tx 11 11/ cm (75%) GV 1.8 Testes 1.5 cm, T3 PH 12 6/ Increased acne cm (70%) Testes 1.5 cm,t3 PH GV / cm (70%) Testes 1.5 cm, late T3 PH GV 9.6 LH 0.6, FSH 0.6, T 7.7, E2 26 LH 0.8, FSH 0.7, T 8.7, E2 4 Stop spironolactone and ketoconazole Continue Lupron and Tamoxifen Lupron Tamoxifen Stop Lupron Continue Tamoxifen

13 Course continued Age Bone age PE Labs Tx 13 0/ cm (70%) Testes 1.8 late T3 PH GV / Testes 1.8/2 late T3 PH No growth LH 0.4, FSH 0.7, T <7, E2 3 LH 6.0, FSH 3.5, T 129, E2 10 Stop Tamoxifen None 13 8/ cm (54%) Testes 2.4 cm R, 3 cm L, T3 PH GV 7.2 None

14 Course continued Age Bone age PE Labs Tx 14 1/ Facial hair, voice change (55%) Tests 2.7 cm R, 3 cm L, earlyt4 PH GV / Testes 3.2, T4 PH No growth /12 Testes cm GV 5.4 cm/yr LH 9.0, FSH 5.2, T 582, E2 44 None None None

15 Environmental Androgen Exposure Original reports of premature sexual development in children from environmental exposures were related to estrogens in products such as cosmetics, hair products, food, and medications Compounds containing androgens have become increasingly available, particularly in topical form, resulting in cases of virilization of exposed children Kuntz et al reported 3 cases exposed to topical testosterone and 2 cases exposed to sports skin tonic called Androsol, which contains 4-androstenediol, with signs of virilization

16 Effect of spironolactone on estradiol levels Androgen receptor blocker Testosterone-estradiol ratio

17 Effect of Tamoxifen on initiation of puberty? Tamoxifen has been shown to decrease hypothalamic LHRH as well as LH pulse frequency in male rats

18 References Balasinor N et al. Mechanism delineating differential effect of an antiestrogen, tamoxifen, on the serum LH and FSH in adult male rats. Journal of Endocrinological Investigation 2006: Hayes FJ et al. Aromatase inhibition in the human male reveals a hypothalamic site of estrogen feedback. J Clin Endocrinol Metab 2000: Kunz GJ et al. Virilization of young children after topical androgen use by their parents. Pediatrics 2004: Rose LI et al. Pathophysiology of spironolactoneinduced gynecomastia. Annals of Internal Medicine 1977: