Clinical_Rounds_in_Endocrinology_Volume_II_-_Pediatric_Endocrinology

19 6

ab

c

Fig. 6.11 (a) Mixed precocious puberty in a 7-year-old boy with congenital adrenal hyperplasia
due to 21α-hydroxylase deficiency after initiation of glucocorticoid therapy. (b) External genitalia
showing stretched penile length 10 cm, Tanner pubic hair stage 2, and bilateral testicular volume
6 ml. (c) X-ray of left hand AP view showing bone age of 13 years

(>10 years in girls and >11 years in boys). This is because advanced bone age

of >10 years in girls and >11 years in boys predicts imminent reactivation of

HPG-axis. Abrupt lowering of persistently elevated sex steroids after initiation

of therapy in a long-standing untreated patient with GIPP results in premature

reactivation of a primed HPG-axis. The management of GDPP superimposed

on GIPP includes GnRH agonist for mixed precocious puberty, in addition to

specific treatment for the primary disorder (Fig. 6.11).

6 Precocious Puberty