05-2013 Case of the Month


What would you do in this this case?

A 6 year/10 month-old African-American female presents with her mother who is concerned about her daughter’s recent breast development in the last few months. The child has no other medical problems or history of surgery. The family history is negative for breast, ovarian and colon cancer. Of note, the mother reports her own menses began at age 9 years and her adult height is 5’6” (167.5 cm). On examination, you note the child is in the 60th percentile for height and weight. She has Tanner 2 breasts and Tanner 1 genitalia. The external genitalia appear normal.

What do you do next in evaluating this child? 

A. Bone age of hand and wrist
B. Pelvic ultrasound
C. Gonadotropin-releasing hormone (GnRH) stimulation test
D. Reevaluate in 2 years to assess progression of puberty
E. Adrenocorticotropic hormone (ACTH) stimulation test
F. Computerized tomography (CT) of the abdomen

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Answer A is CORRECT: Bone age of hand and wrist 
Rationale: A bone age is the most cost effective means of determining any additional steps needed to further assess precocious development or provide reassurance to the parents. If the bone age is >2 standard deviations advanced, further workup is recommended.

Answer B is incorrect: Pelvic ultrasound
Rationale: Although this child exhibits signs of early estrogen production, this may also be normal for her age. Approximately 1/3 of girls will exhibit precocious thelarche with bone age advancement and subsequently go on to develop precocious puberty.

Answer C is incorrect: GnRH stimulation test 
Rationale: A GnRH stimulation test would be appropriate only after a bone age demonstrates advancement over 2 standard deviations, baseline hormones are suggestive of a central process, and a cranial lesion has been ruled out by brain MRI.

Answer D is incorrect: Reevaluate in 2 years to assess progression of puberty
Rationale: It is important to follow these girls every 6 months since even those with isolated pubertal signs may go on to develop precocious puberty requiring intervention.

Answer E is incorrect: ACTH stimulation test 
Rationale: An ACTH stimulation test may be indicated in the setting of ambiguous genitalia or when development demonstrates signs of hyperandrogenism.

Answer F is incorrect: CT of the abdomen
Rationale: A CT of the abdomen is typically reserved for cases when development exhibits signs of hyperandrogenism and adrenal hormones are elevated in the adrenal tumor range.

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