Gonadal dysgenesis with isolated clitoromegaly, XY karyotype, and bilateral gonocytoma with massive Leydig cell hyperplasia

Perspectives in Pediatric Pathology, Chapter 5. Gonadal Dysgenesis

One of the most challenging areas in pediatric testicular pathology is the appropriate understanding and pathological diagnosis of disorders of sexual development (DSD), and in particular, the issue of gonadal dysgenesis. Here we present the main concepts necessary for their understanding and appropriate classification, with extensive genetic correlations.

Hypoplastic uterus and clitoris enlargement in Swyer syndrome

BACKGROUND

Swyer syndrome is associated with absent testicular differentiation in a 46XY phenotypic female.

CASE

A 17-year-old female presented with primary amenorrhea and 46XY karyotype. Breast and pubic hair development were Tanner 2, and clitoral enlargement was noted. Magnetic resonance imaging revealed a hypoplastic uterus and 2 "normal ovaries." Serum follicle-stimulating hormone and luteinizing hormone were elevated. Testosterone and androstenedione were in the female range. Dehydroepiandrosterone sulfate was slightly elevated. Laparoscopic bilateral gonadectomy was performed. Pathology reports showed bilateral microscopic benign hilar cell tumors.

SUMMARY AND CONCLUSION

The diagnosis was a real puzzle for the clinicians because of the association of clitoral hypertrophy without hirsutism, female internal genitalia, and a 46XY karyotype. Clitoral enlargement can be explained by transient androgen secretion by the hilar cells found in the resected gonads.

A virilizing hilus-cell tumour in an African patient with Turner's syndrome

A 26-year-old African female presented with primary amenorrhoea and genital abnormalities. She had the physical stigmata of Turner's syndrome and a 45, X karyotype. Severe masculinization of the external genitalia, apparently present from birth, was present and a laparotomy revealed a hilus-cell tumour of the right streak gonad. Clitoridectomy and vaginoplasty were performed but subsequent oestrogen therapy failed to produce breast development.