Growth impairment in a boy with late-onset congenital adrenal hyperplasia and anorexia nervosa

Abstract

Treatment of congenital adrenal hyperplasia (CAH) in its salt-wasting form with appropriate doses of glucocorticoids and mineralocorticoids should promote growth, puberty and final height in a similar to normal pattern. However, the individual requirements for these drugs to normalize the hormonal profile and to achieve a physiologic growth pattern may differ. Moreover, the time of onset of puberty is also unpredictable since the course of the disease may predispose for precocity. The aim of this study was to explain the unexpected arrest of growth during puberty in a boy with late-onset CAH, who had been treated with glucocorticoid from early childhood. A short course of GnRH agonist treatment was also introduced in later years. The growth chart reflects two periods of impaired growth velocity preceded by weight loss. The reason for the first decline is difficult to prove retrospectively, but during the second episode the boy became both clinically and hormonally hypogonadal. At that time the anorexia nervosa (AN) was diagnosed according to APA DSM-IV criteria. We conclude that there were several reasons for the discontinued growth spurt and reduced final height in this boy with CAH: (a) early variant of puberty and subsequent late treatment with GnRH agonist, (b) AN possibly occurring during mid-childhood and clearly during puberty and (c) the repeated use of high doses of glucocorticoids. AN, a relatively rare disorder in boys, appears to have had a significant negative effect on this patient's growth and should be considered in the differential diagnosis in CAH children with impaired growth.