201 A Case of Intentional Virilization of a Young Female Toddler. The Medical and Legal Consequences

• Published in: Archives of disease in childhood 2021-10, Vol.106 (Suppl 2), p.A85-A85
• Main Authors: Yafi, Michael Yafi, Velez, Katherine, Girardet, Rebecca
• Format: Article
• Language: English
• Subjects: Abstracts; Acne; Adrenocorticotropic hormone; Child sexual abuse; Children; Condoms; Dehydroepiandrosterone; Exposure; Females; Follicle-stimulating hormone; Grandparents; Gynecology; Hormones; Human exposure; Hydrocortisone; Hyperplasia; Karyotypes; Laboratory tests; Luteinizing hormone; Magnetic resonance imaging; Medical Evaluation; Pediatrics; Physical Examinations; Puberty; Testosterone; Toddlers; Tumor markers; Tumors; Uterus
• ISSN: 0003-9888; 1468-2044
• DOI: 10.1136/archdischild-2021-europaediatrics.201

A five- months- old female, born with normal female genitalia, developed clitoromegaly. Physical examination showed a 3 cm length x 0.8 cm width clitoris and Tanner 2 pubic hair/1 breasts.She lived with her biological grandmother and step grandfather. The grandmother worked, while step grandfather was the primary caregiver, during the day.Laboratory testing showed very elevated levels of both total and free testosterone (above 1500 ng/dL: 52 nmol/L ) (402.5 pg/mL), respectively LH and FSH levels were pre-pubertal, 17-hydroxyprogesterone, 11 Deoxycorticosterone, DHEA, ACTH, cortisol, anti-mullerian hormone (AMH), and tumor markers (HCG, AFP) levels were normal.Karyotype was 46XX with FISH negative for SRY. Pelvic MRI showed a uterus with no pelvic masses.When asked about possible exposure to hormones, the step grandfather, aged52 years, stated that he was on testosterone creams and that he was probably accidentally exposed her by holding her after rubbing the cream on his shoulder. Education as to how to avoid exposure was provided. Testosterone levels dropped to 158 ng/dL (5.4 nmol/L) by 3 months after the first visit but went up few months later to 975 ng/dL (33.8 nmol/L) with growth acceleration, clitoral growth of 4.5 cm in length and labial fusion, muscular appearance and acne.At this time, she was hospitalized for 6 weeks and Children’s Protective Services were contacted. The step grandfather was not allowed to see her.The testosterone dropped to a normal level of 3.8 ng/dL (0.13 nmol/L). The child was later was adopted by extended family members.The child’s testosterone level remained undetectable after discharge but her voice remained very deep. She went through clitoroplasty. Her clitoral size was reduced surgically to 2.5 cm length. Her acne has resolved and her mood was pleasant.Law enforcement investigation of the step-grandfather revealed several containers of testosterone products in the home, as well as pornography and multiple used condoms. He was arrested and convicted of committing serious bodily injury to a child, and was sentenced to 20 years in prison.DiscussionVirilization of pre-pubertal girls should prompt a detailed medical work up to rule out a virilization form of Congenital Adrenal Hyperplasia (CAH) or androgen producing tumors. If medical pathologies are ruled out, environmental exposure to testosterone should be suspected.While all of the reported pediatric virilization cases due to hormonal exposure were accidental, this is ca