Precocious puberty and a sellar mass

Van Wyk Grumbach Syndrome and Ovarian Hyperstimulation in Juvenile Primary Hypothyroidism: Lessons From a 30-Case Cohort

Context

Prolonged hypothyroidism in children commonly causes short stature with delayed bone maturation, and delayed puberty. However, a paradoxical occurrence of peripheral precocious puberty and pituitary enlargement in chronically untreated juvenile hypothyroidism was first reported by Van Wyk and Grumbach in 1960.

Objective

To create increased awareness and a better understanding of this clinical entity among emergency room physicians, pediatricians, surgeons, gynecologists and oncologists.

Methods

Case records of children diagnosed with Van Wyk-Grumbach syndrome (VWGS) were analyzed retrospectively.

Results

Twenty-six girls and 4 boys were identified (2005-2020). All had profound primary hypothyroidism (total thyroxine [T4]: 2.5-33.5 nmol/L, thyrotropin: > 75-3744 μIU/mL). Hypothyroidism was not the referral diagnosis in any of the girls. Among them, 17 were referred for precocious puberty, 5 with a diagnosis of pituitary tumor on magnetic resonance imaging, and others for acute surgical abdomen in 7 girls (painful abdominal mass-2, ovarian tumor-2, ovarian torsion-2, ruptured ovarian cyst-1), acute myelopathy in 1, and menorrhagia with headache in another. All girls were successfully managed with levothyroxine replacement alone, except for the 2 with ovarian torsion, who required surgery. Menstruation ceased promptly with T4 therapy in all girls, occurring at an age-appropriate later date. All boys had testicular enlargement at presentation that regressed partially after T4 treatment. Catch-up growth was remarkable during the first treatment year, but the final height was compromised in all.

Conclusion

Increased awareness of varied presentations of VWGS is vital among pediatricians to facilitate early diagnosis and targeted investigations, and to help in the initiation of the simple yet highly rewarding T4 replacement therapy to avoid all possible complications.

Phenotypic presentation of adolescents with overt primary hypothyroidism

BACKGROUND

The phenotypic presentation of overt hypothyroidism during adolescence is less well characterized. The aim of the study was to study the phenotypic presentation of patients with overt hypothyroidism presenting during adolescence (age 9-18 years).

METHODS

Records of adolescent patients with overt hypothyroidism (thyroid stimulating hormone [TSH]>10 mIU/L) were retrospectively analyzed for presenting complaints, height and pubertal status.

RESULTS

A total of 67 patients (40 females and 37 males, average age 13.2+2.3 years) with a mean TSH of 241.3±336.6 mIU/L were included. The commonest presentation was short stature in 46.2% of patients followed by neck swelling (16.4%) and weight gain (11.9%). The mean height standard deviation score (SDS) was -2.5+2.11, 43% of patients had less than 3 SDS. The height age and bone age were around 3 years less than the chronological age. The bone age significantly correlated with the height age but not with TSH levels. Three patients referred from neurology with primary complaints of headache had pituitary hyperplasia and one presented with hypokalemic periodic paralysis. Seven had delayed puberty and one patient had early periods due to huge ovarian cysts.

CONCLUSIONS

In the present study, severe short stature and uncommon phenotypic presentations were a consequence of long-standing severe untreated hypothyroidism.

Primary hypothyroidism with growth failure and pituitary pseudotumor in a 13-year-old female: a case report

Introduction

Primary hypothyroidism is a well-known cause of poor linear growth in children. A rare finding with profound or long-standing disease is anterior pituitary enlargement (pituitary pseudotumor). This case highlights this uncommon finding, discusses clinical situations in which gradual dose escalation of levothyroxine may be advisable and reviews adjuvant therapies that have been previously attempted to improve final height in the setting of profound hypothyroidism.

Case presentation

We report the case of a 13-year-old Hispanic girl initially evaluated for poor linear growth and delayed puberty, and found to have pituitary enlargement secondary to profound primary hypothyroidism. Treatment with progressive doses of levothyroxine normalized her symptoms and led to complete resolution of her pituitary findings, but she then rapidly progressed through puberty, achieving an adult height of only 142cm, significantly below her calculated mid-parental height.

Conclusions

In cases of severe primary hypothyroidism with prolonged elevation of thyroid-stimulating hormone and pituitary pseudotumor, gradual replacement of thyroid hormone with slowly escalating doses of levothyroxine may be beneficial to prevent complications of therapy. Early recognition and treatment of hypothyroidism during childhood is essential for normal growth, as final height is invariably compromised in children with prolonged disease. Additional study is needed to determine the potential beneficial effects of gonadotropin-releasing hormone agonist and recombinant human growth hormone treatment in this setting.