Program Director University of Kentucky Lexington, Kentucky, United States
Case Diagnosis: Precocious Puberty in Severe TBI
Case Description: 6-year-old female who sustained a severe, anoxic brain injury and high incomplete SCI (C1-C2 and C2-C3 malalignment, status post fixation, with partial transection of cervical spinal cord) at the age of 3. The patient was fastened into her car seat but in the front seat, was ejected from the vehicle at the time of collision, found to be in pulseless arrest. On scene, ROSC was obtained, but patient has remained ventilator-dependent since. The patient is currently nonverbal and tetraplegic. When the patient presented to PM&R clinic at 5 y/o, she had breast buds and pubic hair (Tanner Stage III), had not yet started menses, and had never seen Endocrinology. After referral to Endocrinology, labs and advanced bone age on imaging confirmed precocious puberty.
Discussions: Due to the limited number of cases, the mechanism for precocious puberty is not fully understood, but does seem to occur more commonly in severe TBI. One proposed mechanism is increased intracranial pressure on the hypothalamus and pituitary gland in the setting of TBI, particularly severe TBI. Although precocious puberty after TBI is noted as a known possible sequela in resources for PM&R board examinations, it is actually a rare complication when looking at the literature.
Conclusions: This case report re-emphasizes the need for a physiatrist treating children with TBI to maintain a high index of suspicion for precocious puberty. Coordination with pediatricians as well would be ideal; if a TBI patient is found to be advancing physically in a way consistent with precocious puberty on yearly physicals by the pediatrician, the patient can be sent to Endocrinology sooner. When precocious puberty is left untreated, there can be long term physical, social, and psychological effects, which can compound even further in pediatric patients who have already suffered a TBI.
