1. Case Presentation LM – 11/2011

2. Presenting Complaint Current age - 3 Yr 11 mth ♀ Premature pubarche First noticed between 18 mth and 2yr Progressive

3. Additional History Breast development? Strong Increased hair on legs Labile moods – aggressive outbursts Episodes of increased appetite Increased height and weight - 18 mth – 2 yr No acne, BO, axillary hair, clitoral enlargement, PV discharge / blood loss

4. Additional History Normal pregnancy (41/40 gestation) No maternal virilization Birth length – 10 th pc Birth weight – 50 th pc No mention of abnormal genitalia

5. Additional History Recurrent tonsillitis / enlarged tonsils OSA? – snoring, restless sleep T + A No medications No exposure to androgens

6. Additional History No significant FH Parents unrelated MPH = 75 TH – 90 TH pc Tall stature on father’s side Own restaurant Mild delay –Gross motor –speech

7. Examination (3yrs 6 mths) Wt >> 97 th pc, Ht > 97 th pc BMI > 97 th pc Weight age – 8 ½ Height age – 5 ½ Big hands and feet No asymmetry No dysmorphic features No acanthosis nigricans

8. Growth Chart

9. Examination Slight increase in body hair PH - 3 No acne No axillary hair No BO No breast development No clitoral enlargement No labial fusion

10. Investigations 06/2010 (CA 2 1/2) –BA-5yr 9 mth –Karyotype 46XX –Testosterone 1.6 nmol/L (< 0.5) –DHEAS <0.5  mol/L (< 1.0) –17OHP 0.8 nmol/L ( < 3.0) –Androstenedione < 1.0 nmol/L ( < 4.0) –FSH 1.3 U/L ( < 7.0) –LH 0.3 U/L ( < 5.0) –E2 < 30 pmol/L ( < 55)

11. LHRH Stimulation Test TimeLHFSH 00.31.2 450.55.0 500.31.2 600.56.1 750.77.5 900.67.2 1200.68.8 1550.813 LHRH Stimulation – 03/2011 (CA 3yr 3 mth) Arranged by general paediatrician – concerned that she may have precocious puberty

12. Investigations 05/2011 (CA 3 yr 5 mth) – 10:15 –LH< 0.1 U/L(< 5) –FSH0.1 U/L(< 5) –E2< 37 pmol/L (< 55) –ACTH33 ng/L (10 – 50) –Cortisol 416 nmol/L (150 – 700) –Testosterone8.3 nmol/L(0.3 – 2.5) –SHBG27(40 – 90) –DHEAS< 0.5  mol/L(< 1.0) –17OHP1.3 nmol/L(< 3.0) –Androstenedione1.1 nmol/L(< 4.0)

13. Investigations Tumour Markers –  HCG,  FP - negative Karyotype – SRY negative Urinary Free Cortisol Incomplete (1L) – 100nmol/day (80 – 590) Synacthen –Baseline ACTH (ng/L)33 –Cortisol (nmol/L) 416 → 847 –17OHP (nmol/L)1.3 – 1.0

14. Investigations BA – 6 yr 10 mth: CA 3 yr 5 mth US Liver – no masses –Adrenals – normal size, no masses –Ovaries – no masses –Uterus – prepubertal CT – abdomen + pelvis – NAD MRI – pineal gland cyst, no masses in adrenals or ovaries but not well visualised

15. Fluctuating Testosterone DateTimeLevelLab 22/06/201010:151.6 nmol/LQML (< 0.7) 19/05/201110:158.3 nmol/LMHS (0.3 – 2.5) 03/06/201110:351.6 nmol/LMHS (0.3 – 2.5) 06/06/201113:571.0 nmol/LQML (< 0.7) 07/06/201113:343.5 nmol/LQML (< 0.7) 08/06/201115:121.7 nmol/LQML (< 0.7) 16/06/201107:495.6 nmol/LQML (< 0.7) 08/07/201115:121.7 nmol/LQML (< 0.7) 21/07/201108:021.3 nmol/LQML (< 0.7) 28/07/201108:483.3 nmol/LQML (< 0.7)

16. TimeTestCortDex 1100 0.8 462 N 1440 1.0 171 N 2200 3.9 50 N 3000 2.4 175 N 3845 1.7 278 N 4600 3.4 < 50 N 5400 1.0 152 N 6315 0.5 < 50 Y 7005 2.6 < 50 Y 7820 1.6 < 50 Y 8600 1.0 < 50 Y 9410 1.0 < 50 Y 10215 0.9 < 50 Y 11000 0.2 < 50 N 11800 1.3 < 50 N 12600 0.6 123 N 13400 30 127 N 14200 1.0 160 N 15000 0.3 323 N Serial testosterone measurements during inpatient admission 2 nd 48 hrs – dex suppression

17. Further Investigations Urinary steroid profile –X2: pre-dex + last 24 hrs off dex –No abnormal metabolites Confirmation of elevated testosterone –Immunoassay vs chromatography –1.0 nmol/L vs 1.8 nmol/L –30 nmol/L vs 50 nmol/L

18. Adrenal androgen response to ACTH Time0 HR1HR Androstenedione 0.1< 0.1 Testosterone<0.1 DHEAS< 0.5 Cortisol250617

19. GH / IGF-1 1GF-1 –49 nmol/L 03/06/2011 (12 -20) –53 nmol/L 02/08/2011(12 -20) 02/08 03/08 04/08 05/0806/08 11:0014:4022:0006:0014:4506:0015:1522:0522:1006:15 1.73.4180.50.30.80.216203.8 06/0807/08 08/08 22:0006:0014:0022:0006:00 111.31.1131.1 Serial GH measurements (mU/L)

20. HCG Stimulation 2000 units daily for 3 days HormonePrePost Androstenedione< 1.0 nmol/L2.4 nmol/L Testosterone1.2 nmol/L4.4 nmol/L DHEAS< 0.4 micromol/L< 0.4 nmol/L

21. Differential Diagnosis Exogenous ? –Negative history Tumour ? –Isolated elevation of testosterone –Negative imaging and tumour markers –Slowly progressive Gonadal dysgenesis normal karyotype normal mullerian structures no neonatal genital abnormality Functional ? –Sulphation defect –LH receptor activation (no phenotype described in females) –0vergrowth / insulin resistance

22. Questions Pathology Source – Ovary, Adrenal, Other ? Explanation for fluctuation Management

23. Most Recent Testing ACTH stimulation –testosterone – 10 to 12 nmol/L –DHEA 1.7 to 1.9 nmol/L – unlikely to be problem with sulphation OGTT – confirmed insulin resistance Repeat BA – 7 yrs 10 mth (CA 3 yrs 11 mth) – increase of 12 months over last 6 months

24. First 48 hrs no dex; second 48 hrs dex; last 48 hrs no dex Testosterone - normal range 0.3 – 2.5 nmol/L Y 1 axis testosterone nmol/L Cortisol – normal morning range 150 – 700 nmol/L Y2 axis cortisol nmol/L

25. First 72 hrs no dex; second 72 hrs dex; last 72 hrs no dex Testosterone - normal range 0.3 – 2.5 nmol/L Y 1 axis testosterone nmol/L Cortisol – normal morning range 150 – 700 nmol/L Y2 axis cortisol nmol/L