嵌合型Turner综合征并快进展型青春期一例及文献复习

Rapidly progressive puberty in a patient with mosaic Turner syndrome： a case report and literature review

目的探讨嵌合型Turner综合征并快进展型青春期临床诊治特点。方法对2015年1月华中科技大学同济医学院附属同济医院儿科收治的1例延误诊断的核型为45，X／46，X，del（X）（p21）并快进展型青春期的Turner综合征的临床资料及诊治过程进行总结分析，并进行相关文献复习。以“Turner syndrome”“precocious puberty”“rapidly progressive puberty”或“Turner综合征”“性早熟”为检索词，分别检索2016年4月前的PubMed、CNKI和万方数据库。结果本例40周＋1d出生，出生体重2450g。因“生长发育落后”初诊，3岁时诊断为“小于胎龄儿”。4岁时给予基因重组人生长激素治疗9个月，身高增长6．8cm。后因经济原因停用基因重组人生长激素治疗。8岁半因“矮身材”再次就诊，9岁3月龄出现乳腺发育，随访中发现13个月内乳腺发育至B3期、骨龄进展2岁，考虑快进展型青春期，给予促性腺激素释放激素类似物缓释剂治疗。联合治疗过程中，年生长速率由7．5cm／年降至4．4cm／年，重新评估诊断，外周血染色体核型分析结果为45，X／46，X，del（X）（p21）（80％／20％）。共检索到Turner综合征合并性早熟9篇文献，10例病例。其中国外7篇文献（8例），国内2篇文献（2例）。结合本例，目前仅有11例病例报道。临床主要表现为Turner综合征合并性早熟或快进展型青春期。6例为嵌合型，3例为X染色体短臂结构异常，1例为45，X单体。结论首次报道了1例核型为45，X／46，X，del（X）（p21）的并快进展型青春期的嵌合型Turner综合征。Turner综合征并性早熟或快进展型青春期者相对罕见，极易延误诊断或漏诊。有自发性性发育的女孩若身高位于正常低限，或身高在正常范围，但生长速率低于正常，应高度警惕Turner综合征的可能性。

Objective To explore the clinical characteristics of diagnosis and treatment in patients with Turner syndrome and rapidly progressive puberty. Method A rare case of rapidly progressive puberty in Turner syndrome with a mosaic karyotype of 45, X/46, X, del （X） （ p21 ） （ 80%/20% ） was diagnosed at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology in January. 2015. Clinical characteristics and the related literature were reviewed. Original papers on precocious puberty or rapidly progressive puberty in Turner syndrome, published until Apr. 2016 were retrieved at PubMed and CNKI databases by the use of the key words ＂Turner syndrome＂, ＂ precocious puberty＂ and ＂ rapidly progressive puberty＂. Result The patient was born at term with birth weight of 2 450 g and was diagnosed with SGA at 3 years of age for the first evaluating of growth and development. Then recombined human growth hormone （rhGH） was given at 4 years of age due to short stature （ height 〈 3 percentile） and low growth velocity （ 〈 5.0 cm/year） as well. However, rhGH treatment was discontinued after 9 months because of economic burdens. Breast development was noted at 9 years and 3 months. The patient was followed up at 3 months intervals. Physical examination revealed a Tanner stage Ⅲ breast development at 10. 33 years , the bone age was 11.6 years. Then, gonadotropin-releasing hormone analogs treatment was added to slow pubertal progression and to preserve maximum adult height. The growth rate decreased withtherapy from 7.5 crnfyear to 4.4 cm/year. The patient was reevaluated, and the chromosome analysis of peripheral blood revealed a mosaic karyotype 45, X/46,X, del （X） （ p21 ） （ 80% / 20% ）. To date, only 10 cases have been reported in the literature. Six of them showing mosaic TS, three karyotypes with structural abnormality of short arm of X chromosome, one with the karyotype 45, X. Conclusion It is the first time that rapidly progressive puberty in a 45, X/46, X, del （X） （ p21 ） mosaic Turner syndrome is reported. Although short stature and ovarian dysgenesis are common in TS, precocious puberty may occur in TS, which is liable to cause delayed diagnosis and misdiagnosis. Careful examination is recommended for patients with unusual growth pattern, even though girls have normal height in accord with standard growth curve or spontaneous puberty. Evaluation for TS and subsequent investigation should be prompted.